Ask – Don’t assume you already know
Share – With everyone on the team
Plan – Address patient/family-stated
goals/concerns/priorities and use to guide
Plan for the Day and Stay
Asking patients and
families about their
planning and may
impact decisions about
Capturing these goals
to proactively address
patients’ and families’
within the electronic
health record can
patients and families
about their goals.
What Do Nurses Say?
What benefits have you noticed about asking patients
and families about their goals and concerns?
I would not have guessed some of their goals or
concerns. They are different than mine and it is great
that we are on the same page after I do their care plan.
Together we address their concerns and determine how
we are going to attain their goals.
Especially during admission patients have been
impressed that we are doing a better job involving them
in their care planning [saying] "I'm glad you asked me."
Has your understanding of patients’ and families’ goals
and concerns influenced the plan for the day and stay?
Absolutely! When the patient and I develop the plan for
the day and plan for the stay I ensure we have included
how we, the IMOC team are going to achieve their goals
and address their concerns for the day and before they
It is also nice to know goals going into IMOC rounds so
they can be addressed with the entire team present. This
helps me to make sure that the team is on the same page
as the patient.
Klinkner, G., Reis, R., Copus, G., VanDenBergh, S., Hughes, S., Linde, C. (April 2014). Using a Re-designed Interdisciplinary Care Plan to Improve
Communication about Patient and Family Goals. Poster presentation, UWHC/UW-Madison School of Nursing Poster Fair, Madison, WI.