Table 1.

S&I Framework definitions related to longitudinal care plans²⁶

Care plan	Over arching, longitudinal blueprint of all sites and all team members’ (including patients) prioritized concerns, goals, and interventions
Plan of care (POC)	Discipline-specific set of related problems or health concerns. Different plans of care require reconciliation into a single care plan. Examples: acute care POC and home care POC
Treatment plan	Focuses on a specific health concern and typically managed by one clinician. Example: physical therapy treatment plan
Health concerns (used by S&I Framework in lieu of ‘problems’)	The issues, current status, and ‘likely course’ identified by the patient or team members that require intervention(s) to achieve the patient’s goals of care, any issue of concern to the individual or team member
Goal	A defined outcome or condition to be achieved in the process of patient care. Includes patient defined goals (eg, prioritization of health concerns, interventions, longevity, function, comfort) and clinician-specific goals to achieve desired and agreed upon outcomes
Patient instructions	Information or directions to the patient and other providers including how to care for the individual's condition, what to do at home, when to call for help, any additional appointments, testing, and changes to the medication list or medication instructions, clinical guidelines, and a summary of best practice. Detailed list of actions required to achieve the patient’s goals of care
Responsible clinicians	Parties who manage and/or provide care or service as specified and agreed to in the care plan, including clinicians, other paid and informal caregivers, and the patient
Interventions	Actions taken to maximize the prospects of achieving the patient’s or providers’ goals of care, including the removal of barriers to success. Instructions are a subset of interventions
Outcomes	Status, at one or more points in time in the future, related to established care plan goals