How to Develop a Care Plan

  • The plan should include information about:
    • health conditions
    • medications
    • healthcare providers
    • emergency contacts
    • caregiver resources
  • Having and maintaining a care plan will help you balance both your life and that of the person you are providing care


Basic Information about the Care Recipient


Date of Birth

Social Security # (for doctor / hospital visits)

Phone #



Emergency Contacts


Relationship to Care Recipient


Phone #

More Information

Tell some things about the care recipient that would help visitors and caregivers get to know the person better and be able to socialize and care for the person in the best ways.

Favorite books, movies, songs, things to do (take walks, color, play cards, watch birds, etc.), and other favorites:

Things they enjoy talking about and stories they like to tell about their life:

About their family:

Things they would like to learn about or learn to do:


Name of each condition

Health care provider for each condition

Medications for each condition

Things that help each condition (diet, resting, exercise)


Name of each medication

Instructions for each medication (take on empty stomach, keep refrigerated, etc.)


Times to take it

Potential side effects

Side effects care recipient has had

Healthcare Providers




Phone Numbers for office and after hours

Health Insurance

Health Insurance Company

Phone Number

Preferred Hospital

Hospital Name


Phone #


Name of each caregiver

Services provided (shower, light house cleaning, cooking, etc.)

Days and Hours

Telephone #

Advanced Care Plan

Check the medical Advanced Care Planning topics that you have discussed with your health care provider:


___Advanced Directive or Living Will

This is a legal document (not a medical order), to appoint someone as your legal representative and provides instructions about how you wish to be treated and cared for at the end of your life. Because it is not a medical order, it is not used to help doctors, emergency medical technicians, or hospitals treat you in an emergency.


___Power of Attorney

This legal document is used for you to give a specific person the ability to make decisions for you when you are unable to do so. It can be a spouse, adult child, family member, or friend. You can also name an alternate person in case something happens to the primary person you name. The power of attorney is usually part of the Advanced Directive, but is sometimes a separate document. Sometimes, depending on where you live, it is called a “medical (or healthcare) power of attorney,” “medical proxy,” or “healthcare agent.”


___Physician (or Medical) Orders for Life-Sustaining Treatment (POLST or MOLST) or Physician Orders for Scope of Treatment (POST)

This document, which varies by state, is a medical order signed by a medical professional and used for treatment. It is generally used when a person is nearing the end of life, such as with a terminal or serious illness. This is a document that your doctor can discuss with you during your Advanced Care Planning discussion. This does not name a “surrogate” or “medical proxy.” This document would be used together with the Living Will/Advanced Directive to guide your loved ones and your doctors in the event that you are unable to make your own decisions

The following documents will be attached to this Plan:

___Advanced Directive or Living Will

___Power of Attorney

___Orders for Life-Sustaining Treatment or Scope of Treatment

Plans for follow-up: Ask your medical provider to explain situations when you should call the doctor’s office, report to an emergency room, or schedule a regular follow-up appointment. What are signs and symptoms you and/or your caregiver should look out for? Make sure you write on a calendar all appointments for all caregivers to see.

• I have thought about what medical treatment will mean for me and have discussed it with my family, caregivers, and medical providers

• This plan reflects an outline of my current medical management and plans along with those involved in my medical care.

I have given a copy of my Care Plan to:










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