Overview
Care Plan 2.0 is designed to help care teams create comprehensive, patient-centered care plans while maintaining consistency, efficiency, and regulatory compliance. Following best practices ensures that Care Plans remain accurate, clinically relevant, and useful throughout the patient's care journey.
This guide summarizes recommended workflows, documentation standards, and answers to common questions about using Care Plan 2.0 effectively.
Care Plan Best Practices
Create Patient-Specific Care Plans
Although templates and copied Care Plans significantly reduce documentation time, every Care Plan should be individualized. Before completing the Care Plan:
Review the patient's current medical history.
Verify medications and allergies.
Confirm diagnoses.
Update social history.
Remove unnecessary template content.
Add patient-specific goals and interventions.
Each Care Plan should accurately reflect the patient's current health status.
Keep Documentation Current
A Care Plan is a living clinical document. Review and update it whenever there are significant changes, including:
New diagnoses.
Medication changes.
Hospitalizations.
Emergency department visits.
New laboratory findings.
Changes in functional status.
New Social Determinants of Health (SDOH).
Changes in caregiver support.
Regular updates ensure that the Care Plan continues to guide appropriate patient care.
Complete Every Required Section
Before submitting a Care Plan for physician approval, verify that all required sections have been completed. Typical sections include:
Patient Information
Medical History
Family History
Lifestyle
Assessments
SDOH
Vitals
Preventive Services
SMART Goals
Interventions
Self-Management
Risk Classification
Evaluation Notes
Care Team Review
Incomplete Care Plans may delay approval or require additional revisions.
Use SMART Goals
Goals should always be:
Specific
Measurable
Achievable
Relevant
Time-bound
Instead of:
Improve blood pressure
Use:
Maintain blood pressure below 130/80 mmHg within the next 90 days through medication adherence, dietary modifications, and daily home monitoring.
Clearly defined goals improve patient engagement and make progress easier to evaluate.
Create Actionable Interventions
Interventions should describe exactly what the care team will do. Good examples include:
Review medications monthly.
Monitor blood pressure weekly.
Schedule cardiology consultation.
Educate the patient on sodium restriction.
Review RPM readings every week.
Avoid vague interventions such as "Provide education" without specifying the topic or frequency.
Encourage Patient Self-Management
The Care Plan should empower patients to actively participate in their own care. Examples include:
Measure blood pressure daily.
Take medications as prescribed.
Follow a diabetic meal plan.
Walk for 30 minutes five days per week.
Contact the clinic if symptoms worsen.
Patient engagement improves long-term outcomes and supports successful chronic disease management.
Review Assessments Regularly
Assessment results should not remain static. Review assessment outcomes during:
Care Plan evaluations.
Monthly follow-ups.
Annual Wellness Visits.
Significant clinical changes.
New assessment findings may require updates to goals, interventions, or Risk Classification.
Keep Risk Classification Current
Risk Classification should reflect the patient's current condition. Review risk level whenever there are changes such as:
New chronic conditions.
Frequent hospitalizations.
Medication complexity.
Poor adherence.
Functional decline.
New SDOH challenges.
Accurate risk classification helps prioritize patient outreach and care coordination.
Use Templates Appropriately
Templates should improve efficiency—not replace clinical judgment. After applying a template:
Remove irrelevant goals.
Update interventions.
Modify preventive services.
Personalize patient education.
Verify medications.
Update follow-up recommendations.
Every Care Plan should be tailored to the individual patient.
Document Time Accurately
When using the Billing Timer:
Start the timer before beginning patient-related work.
Stop it promptly after completing the activity.
Record only qualified care management services.
Add meaningful notes describing the work performed.
Review cumulative monthly time regularly.
Accurate time documentation supports compliance and billing.
Obtain Physician Approval Promptly
Do not delay physician review after completing the Care Plan. Before submission:
Verify documentation.
Review goals.
Confirm interventions.
Check medication accuracy.
Resolve incomplete sections.
Respond quickly to any requested revisions to avoid delays in activating the Care Plan.
Review PDFs Before Sharing
Before generating Provider or Patient PDFs:
Verify patient information.
Review medications.
Confirm goals.
Check physician approval status.
Ensure no draft information remains.
Always generate a new PDF after significant Care Plan updates.
Preserve Historical Information
Avoid deleting valuable clinical information. Instead:
Complete evaluations.
Create updated Care Plans.
Switch programs when appropriate.
Maintain historical records for reference.
Historical documentation provides valuable context during future patient encounters.
Documentation Tips
High-quality documentation should be:
Accurate
Complete
Timely
Patient-specific
Objective
Clinically relevant
Easy to understand
Avoid unnecessary duplication and ensure all entries accurately reflect the care provided.
Collaboration Best Practices
Care Plans are most effective when developed collaboratively. Encourage communication between:
Care Coordinators
Physicians
Nurses
Specialists
Behavioral Health Providers
Pharmacists
Caregivers (when appropriate)
Collaborative care planning improves coordination and reduces gaps in care.
Data Quality Best Practices
Before saving any Care Plan, verify:
Correct patient selected.
Current medications listed.
Allergies updated.
Diagnoses confirmed.
Duplicate interventions removed.
Goals are measurable.
Dates are accurate.
Notes are complete.
Routine quality checks reduce documentation errors.
Security & Privacy Best Practices
When working with Care Plans:
Access only patients you are authorized to manage.
Log out when leaving your workstation.
Do not share patient information through unsecured communication channels.
Verify recipient identity before sharing Provider or Patient PDFs.
Follow your organization's HIPAA and privacy policies at all times.
Frequently Asked Questions (FAQs)
General Questions
What is Care Plan 2.0?
Care Plan 2.0 is HealthArc's enhanced care planning solution that enables healthcare organizations to create, manage, review, approve, and maintain patient-centered Care Plans across multiple care management programs.
Who can create a Care Plan?
Users with the appropriate permissions—such as Care Coordinators, Nurses, and Care Managers—can create Care Plans. Physician approval requirements vary based on organizational workflow.
Can multiple users work on the same Care Plan?
Yes. Multiple authorized users may contribute to a Care Plan, with updates tracked through the system's audit history and version control.
Care Plan Creation
Should I always use a template?
No. Templates are recommended when appropriate, but users can also create Care Plans from scratch or copy an existing plan. Regardless of the starting point, each Care Plan should be customized for the individual patient.
Can I edit a Care Plan after it is created?
Yes. Authorized users can edit Care Plans according to their organization's permissions and workflow. Significant changes may require a new physician approval cycle.
Can I copy a previous Care Plan?
Yes. Care Plan 2.0 allows users to create a new Care Plan by copying an existing one, helping reduce repetitive documentation while preserving historical records.
Templates
Does editing a patient's Care Plan update the template?
No. Templates and patient Care Plans are independent. Changes to one do not affect the other.
Can templates be updated?
Yes. Administrators can modify templates, and updates apply only to Care Plans created after the template is revised.
Assessments & Goals
How often should assessments be reviewed?
Assessments should be reviewed during scheduled evaluations, annual reviews, and whenever there are significant changes in the patient's condition.
Can SMART Goals be changed later?
Yes. Goals should be updated as the patient's health status, treatment plan, or progress changes.
Physician Approval
Is physician approval required for every Care Plan?
Approval requirements depend on your organization's workflow and regulatory requirements.
What happens if a physician requests changes?
The Care Plan is returned for revision. After making the requested updates, the care coordinator can resubmit it for approval.
Evaluations
How often should Care Plans be evaluated?
Evaluation frequency depends on the care management program, organizational policies, and the patient's clinical needs.
Can evaluations update the Care Plan?
Yes. Evaluations are intended to review patient progress and identify changes that require updates to goals, interventions, medications, or other Care Plan sections.
Program Switching
Will switching programs delete previous Care Plans?
No. Previous Care Plans remain available as historical records, while a new Care Plan is created for the selected program.
Can information be copied into the new program?
Yes. Relevant clinical information can be copied and then reviewed and customized for the new program.
Billing & Time Logging
Does the Billing Timer automatically create a claim?
No. The Billing Timer records qualifying activities and cumulative time. Claim creation follows your organization's billing workflow.
Can I manually enter time?
Yes, if your organization has enabled manual time entry. Manual entries should accurately reflect qualified care management activities and include supporting notes.
PDFs
What is the difference between the Provider PDF and Patient PDF?
The Provider PDF contains comprehensive clinical documentation for healthcare professionals, while the Patient PDF presents a simplified version focused on education, goals, and self-management.
Will a generated PDF update automatically if the Care Plan changes?
No. PDFs are snapshots of the Care Plan at the time they are generated. A new PDF must be generated after any significant updates.
Security
Who can view Care Plans?
Only authorized users with the appropriate permissions can access patient Care Plans.
Are historical Care Plans retained?
Yes. Historical Care Plans remain available for reference, supporting continuity of care, compliance, and audit requirements.