The perfect baseline care plan and comprehensive care plan in the nursing home have evolved into the holy grail of regulators, malpractice attorneys, directors of nursing, minimum data set coordinators, nurse educators, interprofessional team members, although not so much for direct care staff. In this article, I assert that we expect too much from this document because we do not properly understand its origins, evolution in policy and practice, and its historic misuse as a placeholder for the limited presence of registered nurses (RNs) in American nursing homes.

Nursing care plans were the invention of early 1900s nursing faculty only as a didactic technique. Because hospitals were staffed by student nurses, the care plan identified nursing care activities routinely provided to patients, while simultaneously educating them about the behavioral and cognitive skills required to provide competent nursing care.

Following World War II, two seminal trends emerged that continue to impact nursing as a discipline. A national nursing shortage was solved, in part, by the development and use of nursing assistants, licensed vocational/practical nurses, and hospital-based diploma nurse graduates. Simultaneously, an academic consensus emerged that the university and the baccalaureate degree were essential in the professional RN’s development of core competencies as a clinician and team leader. These two trends manifested themselves in the workplace in ways that are still relevant. The RN became the designated clinical and managerial problem solver and team leader while other nursing staff were identified as the direct care workforce. Hence, in practice nurses experienced a demarcation between cognitive and technical nursing practice. The development of the nursing skill mix (e.g., a collection of nursing staff with differing levels of educational preparation and licensure) led, in large part, to team and functional care delivery models of nursing care.

In the 1950s, PhD-prepared nurses and researchers worked to delineate the unique domain of the RN, in contrast to other members of the nursing skill mix. Dr. Ida Orlando, a prominent nurse researcher, identified the “nursing process” or problem solving, as the RN’s unique cognitive skill. This was defined as a linear process codified as the assessment, definition of a problem, planning, and implementation of care. The nursing process and its associated nursing care plan became embedded in the curricula of baccalaureate and post-graduate nursing education. This competency was integrated into state nurse practice acts and the American Nurses Association (ANA) standards of practice. 

In 1965 the care plan document was included as a Medicare Condition of Participation (COP) in the federal Medicare and Medicaid skilled nursing facility programs. Four years later, in 1969, the nursing care plan document became the Joint Commission on Accreditation of Hospital Organizations (JCAHO, now called The Joint Commission or TJC) standard. In 1987, the Omnibus Budget Reconciliation Act (OBRA) of 1987 mandated that the interdisciplinary care plans replaced the nursing care plan. Finally, in 1991 the interdisciplinary care plan was renamed as the comprehensive care plan.

Currently, the plan of care and the care planning process are referred to in federal regulations, including:

§483.10(b) Exercise of Rights; §483.10(c) Planning and Implementing Care; §483.10(f) Self-determination; §483.15(c) Transfer and discharge; §483.20(b) (c) (d) Comprehensive Assessments; § 483.21(a) Baseline Care Plans; §483.21(b) Comprehensive Care Plans; § 483.24 Quality of Life; § 483.25 Quality of Care; §483.35 Nursing Services; §483.40 Behavioral Health Services; §483.65 Specialized Rehabilitative services; and §483.70(o) Hospice Services.

The care plan document is an essential means by which quality of life and care is enhanced in the nursing home. However, empirical evidence of its efficacy is limited. In an upcoming article, extant practices related to the care plan document will be summarized as well as suggestions about how the comprehensive care plan document may be re-imagined to better serve both residents and nursing staff.

For a more in-depth analysis of the care plan in nursing homes see:

• Dellefield, M. E. (2006). Interdisciplinary care planning and the written care plan in nursing homes: A critical review. The Gerontologist, 46(1), 128-133.
• Dellefield, M. E., & Corazzini, K. (2015, October). Comprehensive care plan development using resident assessment instrument framework: Past, present, and future practices. In Healthcare (Vol. 3, No. 4, pp. 1031-1053). MDPI.