A care plan is a written document that describes a person's care needs, the goals of their care, who is responsible for what, and how and when care should be provided. It is the reference document for everyone involved in care, ensuring consistency across caregivers and reducing the chance that important needs are missed.

Do family caregivers need a formal care plan?

Family caregivers benefit significantly from even an informal written plan. A care plan does not need to use clinical language or follow a professional format. What matters is that it captures the important information in writing so that any caregiver, including a substitute or respite carer, knows what to do, how to do it, and what to watch for.

What should be included in a care plan?

A practical care plan includes: the care recipient's personal information and medical summary, current care needs and how each is met, daily routine, medications and administration instructions, dietary and nutritional needs, communication and cognition information, emergency contacts and crisis plan, and names of who is responsible for each area of care.

How often should a care plan be updated?

Review your care plan whenever there is a significant change: a new diagnosis, a hospitalisation, a change in medications, a decline in mobility or cognition, or a change in who is providing care. As a minimum, review it every six months even if nothing seems to have changed. Care situations evolve gradually in ways that are easy to miss until you see the previous version.

Who should have access to the care plan?

Everyone involved in the care of the person should have access: all family caregivers, any professional carers, the GP (who may have their own version but should know yours exists), and any emergency services or respite providers who may need to step in at short notice.

How to Write a Care Plan: A Practical Template for Family Caregivers

Most family caregivers operate without a written care plan, relying instead on memory, habit, and informal communication. This works until the primary caregiver is unavailable, a new person joins the care team, something goes wrong, or a doctor asks a question that nobody can answer clearly. A care plan exists precisely for these moments.

📋 In this guide

What a care plan is and who it is for
The sections every family care plan should include
A practical template you can use immediately
How to keep the plan current without it becoming a burden
How to use your care plan across a team

What a Care Plan Is (and What It Is Not)

A care plan is a written reference document that describes what a person needs, how those needs are met, and who is responsible for what. It is not a medical document. It does not require clinical language, professional qualifications to write, or approval from any authority. It is a practical organisational tool that any family can create and maintain.

A family care plan has one essential quality: it must be accurate enough that someone who does not know your loved one at all could use it to provide reasonable care in an emergency. If it passes that test, it is good enough.

"A care plan is not paperwork. It is the document that ensures a stranger can care for your loved one safely, and that everyone involved is working from the same version of the truth."

Section 1: Personal Information and Medical Summary

Start with the basics. This section should be findable by a paramedic or an emergency room nurse in under a minute.

Personal details:

Full name and preferred name
Date of birth
Address
NHS number (UK) / health insurance / Medicare number
GP name, practice, phone

Medical summary:

Primary diagnosis
Secondary conditions
Known allergies (clearly marked)
Blood type
Current medications (or a reference to the medication section)
Significant recent history (hospitalisations, surgeries)

Emergency contacts (with relationship and best time to reach):

First contact: name, relationship, phone
Second contact: name, relationship, phone
Named GP after hours contact

Keep this section short and visible. It is the section under pressure, not the section for nuance.

⚠️ Allergies must be explicit and prominent

Do not bury allergy information inside a paragraph. Use a clear format: "ALLERGIES: Penicillin (severe reaction), Latex, Aspirin (gastric). NO NSAIDS." Any substitute carer, paramedic, or emergency clinician needs to see this immediately.

→ Store your care plan in Care Maple's document vault where every team member can access it

Section 2: Daily Routine

Document the day in sequence. This section makes handovers possible and ensures consistency across caregivers.

Morning routine (time, in sequence):

Wake time and how they typically wake
Personal care: washing, oral hygiene, dressing (include any assistance needed and how it is provided)
Breakfast: what, how much, any specific preparations

Daytime routine:

Medication schedule
Mealtimes and preferences
Activities: what the person enjoys and what they can manage
Rest periods if relevant

Evening routine:

Evening meal
Evening personal care
Bedtime routine and preferred time
Night-time: any expected wake-up, any safety concerns

Notes on variation: How does the routine change on medical appointment days? What happens when the person has a bad day? What adjustments are needed?

💡 Write the routine as though explaining it to someone who has never met the person

Include the context that experienced carers take for granted. "She prefers to wash herself if given time, but needs assistance with her back and feet" is more useful than "she washes independently." The goal is for a substitute carer to provide care safely and with dignity without having to guess.

Section 3: Current Care Needs

List every area where support is needed and what that support looks like. Use a simple format:

Area of need: Description of what is needed and how to provide it.

Common areas to cover:

Personal care (bathing, oral hygiene, hair, nails)
Mobility and transfers (standing from a chair, walking aids, wheelchair use)
Continence (any incontinence, any catheter care)
Nutrition and hydration (dietary restrictions, swallowing needs, portion preferences)
Medication administration
Wound or skin care
Communication (any language, hearing, or cognitive considerations)
Safety (fall risk, wandering risk, any prohibited activities)

For each need, note: what it is, how it is provided, any equipment needed, and any preferences of the care recipient.

Section 4: Medications

Either include a full medication list here or reference a separate medication record. The minimum needed in the care plan is:

Each medication name and dose
When it is taken
Method (tablet, liquid, patch, injection)
What it is for (briefly)
What to watch for if a dose is missed or a reaction occurs

Managing medications for an older adult requires this information to be written down and current. Do not rely on anyone knowing this from memory.

Section 5: Communication and Cognition

This section matters enormously for carers who are new to the person. It addresses how to communicate effectively and what cognitive or communication challenges exist.

Include:

Language(s) spoken and primary language
Any hearing impairment and how it is managed (hearing aids: which ear, how to insert)
Any vision impairment
Cognitive status: is the person oriented to time and place? Any memory concerns? Any dementia diagnosis?
How the person prefers to be addressed (title and surname, first name, nickname)
Communication approaches that work
Triggers for distress and what helps
Anything that is commonly misunderstood about the person

💡 Include the person's personality, not just their needs

A good care plan captures the person, not just their condition. A note that says "She was a headteacher and values being addressed formally. She is proud of her independence and finds being assisted with personal care difficult emotionally. Acknowledge her competence and give her as much control as possible" transforms a carer's approach from functional to genuinely person-centred.

Section 6: Who Does What

Name the people involved in care and what they are responsible for. This is the role assignment section.

For each key responsibility, note who holds it. Common responsibilities:

Care coordination: [name]
Daily hands-on care: [name] / professional carer [name]
Medication management: [name]
GP and medical liaison: [name]
Finances and paperwork: [name]
Family communications: [name]

When roles are named, responsibility is clear. When roles are collective ("the family"), they are no-one's in particular.

Defining care team roles before a crisis means every person involved knows exactly what they are responsible for. Include contact details for each person so any substitute carer can reach the right person quickly.

→ Assign roles and tasks to named team members in Care Maple

Section 7: The Crisis Plan

What to do when something goes wrong, written down before anything goes wrong.

Include:

Who to call and in what order
When to call emergency services versus the GP versus a named family member
Location of advance care documents (power of attorney, advance directive)
DNACPR status if applicable and where the document is
Any known wishes about hospitalisation (does the person want to be taken to hospital, or would they prefer treatment at home?)
Preferred hospital if there is a choice

Advance care planning documents should be referenced here with their physical and digital locations.

Keeping the Plan Current

A care plan that is twelve months out of date is less useful than no care plan at all, because a reader might trust it incorrectly. Review and update it:

After every hospitalisation or significant health event
After every medication change
When a new caregiver joins the team
After a significant change in functional ability
At a minimum every six months

The easiest approach is to store the care plan in your shared care record where it can be updated by any authorised team member and where the version history shows what changed and when.

Coordinating care across a family over time requires a living document that everyone can see and that reflects the current reality of the care situation. A well-maintained care plan is the backbone of that coordination.

A care plan is one of the most valuable things you can create for your loved one and your care team. Start your Care Maple circle today and build the shared record that makes every carer more confident and every handover more reliable.

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