Patient care plans are structured clinical documents used by healthcare professionals to ‘organize, communicate, and guide patient treatment’ (CDC, 2024). They provide an overview of a patient’s prior health issues, current conditions, and specific care needs. 

• These documents typically include information such as patient history, diagnoses, treatments, and clinical progress. 

• Although specific content may vary, patient care plans generally follow a consistent structure that includes an initial assessment/diagnosis, a plan of care, progress notes, and a discharge summary. 

The primary purpose of a care plan is not only to document the care process but also to support clinical decision-making and ensure clear communication among healthcare providers. This reduces miscommunication between clinicians and promotes more consistent patient care. Additionally, it serves as a shared reference point that allows all members of the healthcare team to align their interventions and track patient progress over time. It also promotes accountability by clearly defining goals, responsibilities, and expected outcomes at each stage of treatment.

It’s important to recognize that a patient’s care plan is a form of professional writing that prioritizes clarity, accuracy, and effective communication. Characteristics of patient planning include:

• A highly standardized structure, precise and objective language, and a strong emphasis on evidence-based reasoning. 

• Patient care plans are often structured chronologically to guide the reader from the beginning of a patient’s treatment through to their current condition and progress. 

• The information is organized in a consistent, segmented format that allows for efficient scanning and quick interpretation. 

• Language used should be concise and objective, attempting to avoid vagueness or subjective wording.

However, language can sometimes vary between providers, which may lead to miscommunication or inconsistencies in interpretation. This is a collaborative document and will not always be viewed by a single individual. Therefore, it is essential to use standardized acronyms, terminology, and language that are commonly accepted within the clinical context to ensure clear and accurate communication.

When writing the various documents as listed in the Contexts of the PT Planning Genre System section of the handbook, it is important to base your writing on the context of the document. For example, if you are writing progress notes or a POC to be submitted to insurance or other professionals, it is important you use correct terminology. On the other hand, when you are giving a patient-friendly POC, or responding to patient emails, it is important that you code switch the medical terminology into a form of speech your patient can understand.

When making a diagnosis, and writing your POCs and progress notes, a general formatting guideline to use is the SOAP format. The acronym SOAP stands for:

Subjective – This is what the patient has to say about their condition

Objective – These are the actual results of various examinations

Assessment – This is the conclusion the PT comes to based on the subjective and objective portions

Plan – These are the plans moving forward that the PT will take based on their assessment take based on their assessment

This format of writing creates an organized approach to your patient planning that both you, your patients, and other professionals can follow. Although this method is a common standard in organizing patient plans in the healthcare field, it should be approached with flexibility, and with a non-professional viewpoint in mind to ensure proper communication between the PT and their patient (Physiopedia, 2019).

Code switching examples of effective communication with patients at each phase of the care plan:

*Remember to keep the rhetorical goals in mind from both a clinician and patient perspective*

Scenario #1 Initial Evaluation/Diagnosis:

Rhetorical goals:

Clinician:  Establish trust and credibility

Patient: Build trust and gain knowledge

• Ask what the patient believes is wrong and then use what you know as a clinician to guide treatment.

Code Switch Example: Use, "Your knee isn't bending fully and the muscles supporting it are having to work twice as hard resulting in your pain" instead of, "Decreased ROM and quadricep activation deficits."

Scenario #2 POC:

Rhetorical goal: Get insurance to approve treatment and get patient to commit 

• Are goals SMART (Specific, Measurable, Attainable, Relative, and Timely)

Code Switch Example: "We want you to fully bend your knee enough to perform daily tasks like sitting or using stairs normally within a month." Instead of, "Increase knee flexion + extension to 90-120 degrees within 4 weeks."

Scenario #3 Progress Notes:

Rhetorical goal: Show proof of efficacy to insurance companies and from the patient's perspective they want to be show proof that POC is working.

• Ask yourself, can improvement be explained or demonstrated with clarity? If not, why?

Code Switch Example: "You're improving, just slower than we anticipated. So, we're going to change some of the exercises to keep you on the right track." Instead of, "you're experiencing a strength plateau so were going to modify the stimulus to ensure continued adaptation."

Scenario #4 Discharge Summaries:

Rhetorical goal: 

Clinician: Document positive outcomes

Patient: Leave feeling better and confident with the approach for the future

• Ask if the patient knows how to self-manage once they are no longer under your care

• Ask if the patient knows exactly how/what improved

Code Switch Example: "We have made enough progress to where you're strong enough to resume normal daily activities. Just make sure you continue these exercises" Instead of, "Patient achieved full functionality in aggravated joints + movement patterns in sagittal plane"