A chronic care plan is the written plan a primary care team makes with a patient who has two or more long-term conditions: their goals, the targets, who does what, and what to do if things get worse. Copy the free template, see a diabetes and kidney disease plan and a COPD and heart failure plan, and check what goes in each part.
Blank chronic care plan template
FreeCHRONIC CARE PLAN Patient: [Name, date of birth] Plan date: [Date] Plan status: [New plan, or update of the plan dated] Lead clinician: [Name, credentials] Care coordinator: [Name, role, and direct phone] Present at planning: [Patient, and caregiver, family, or interpreter] Communication needs: [Preferred language, interpreter, hearing, vision, or reading support] WHAT MATTERS TO THE PATIENT In their words: [What matters most to the patient right now] Patient's goals: [Two or three goals the patient chose, such as an activity to keep doing] Barriers: [Cost, transport, memory, mood, living alone, or caregiving duties] Advance care planning: [Wishes discussed, the person who decides if the patient can't, and documents on file] PROBLEM LIST Condition 1: [Diagnosis, year diagnosed, and status: at target, improving, not at target, or worsening] Condition 2: [Diagnosis, year diagnosed, and status] Condition 3: [Diagnosis, year diagnosed, and status, or none] Other issues: [Pain, falls, mood, memory, frailty, or social needs] Allergies: [Drug and reaction, or none known] Medications: [Reconciled list attached, with the date and the source checked] TARGETS Target 1: [Measure, today's value, the target, and the date to reach it] Target 2: [Measure, today's value, the target, and the date] Target 3: [Measure, today's value, the target, and the date] Patient's own measure: [Something the patient can track, such as steps, stairs, or a symptom score] PLAN BY CONDITION Condition 1: [Medications started, changed, or stopped; tests and how often; referrals] Condition 2: [Medications, tests, and referrals] Condition 3: [Medications, tests, and referrals] Medication safety: [Drugs to avoid, sick-day rules, and pill organizer or blister packs] SELF-MANAGEMENT AND RESOURCES Patient's actions: [What the patient agreed to do, and how often] Home monitoring: [Device, how often, and where readings are recorded] Education given: [Topics covered, checked by teach-back, and materials given] Programs and community services: [Self-management classes, rehabilitation, home care, meals, transport, or caregiver support, with contacts] CARE TEAM Clinician: [Name and responsibilities] Nurse: [Name and responsibilities] Pharmacist: [Name and responsibilities] Care coordinator: [Name and responsibilities] Specialists and others: [Name, service, and what they manage] Patient: [Responsibilities] Caregiver: [Name, relationship, phone, and responsibilities, or none] ACTION PLAN Green, doing well: [Usual symptoms and readings, and what to keep doing] Yellow, getting worse: [Warning signs and readings, what to do, and who to call the same day] Red, emergency: [Danger signs, and to call 911 or go to the nearest emergency department] After hours: [Number to call when the clinic is closed] CHECK-INS AND REVIEW Between visits: [Who contacts whom, how often, and by phone, video, or portal] Readings to send: [Which readings, and how] Tests due: [Each test and its date] After an emergency visit or hospital stay: [Who to tell, and follow-up within how many days] Next review: [Date, and sooner if a target is missed or something changes] AGREEMENT Patient agreement: [Plan discussed and agreed, and consent to share it with the care team] Copies given to: [Patient, caregiver, home care, pharmacy, or specialists, and how] Patient or decision-maker: [Signature and date] Clinician: [Name, credentials, signature, and date]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Family practice, new care plan, planning visit with the practice nurse
67-year-old woman, retired school secretary, lives with her husband. “I don’t want to end up on dialysis like my brother.” Wants to keep picking up her granddaughter from school twice a week, and to walk to choir practice again without knee pain. Barriers: worried about the cost of new medicines, and often forgets her evening tablets. No advance care plan yet; her husband would decide for her if she couldn’t. Agreed to talk about it at the next review.
1. Type 2 diabetes for 11 years: not at target. A1c 8.4%, from 7.8% a year ago; no low blood sugars. 2. Hypertension for 9 years: not at target. Office 148/88; home average 142/86 from 14 readings over 7 days. 3. Chronic kidney disease, stage G3a A2, from diabetes and hypertension: eGFR 52 mL/min/1.73 m², from 55 a year ago; urine albumin-to-creatinine ratio 9.5 mg/mmol (84 mg/g), confirmed on a second sample; potassium 4.6 mmol/L. Other issues: knee osteoarthritis, taking ibuprofen 400 mg most days; BMI 32. No known drug allergies. Medications reconciled with her pharmacy today: metformin 1000 mg twice daily, lisinopril 40 mg daily, atorvastatin 40 mg daily.
A1c: 8.4% now; below 7.5% by February 2027, agreed to keep her clear of low blood sugars. Blood pressure: home average 142/86 now; below 130/80 by January 2027. Urine albumin: 9.5 mg/mmol (84 mg/g) now; at least 30% lower by May 2027. eGFR: 52 now; keep it steady, allowing for a small drop when the new medicine starts. Weight: 86 kg (190 lb) now; 82 kg (181 lb) by May 2027. Her own measure: walking to choir practice, about 15 minutes, by March 2027.
Diabetes: start empagliflozin 10 mg each morning, chosen to protect her kidneys and heart as well as lower glucose. Metformin stays at 1000 mg twice daily, with breakfast and dinner, and a phone alarm for the evening dose. If the A1c is still above 7.5% in February, add a GLP-1 receptor agonist. Feet checked today: low risk. Retinal exam last done in 2024: referred. Hypertension: continue lisinopril 40 mg. Empagliflozin should lower her pressure a little; if the home average is still above 130/80 at 4 weeks, add amlodipine 5 mg daily. Kidney disease: creatinine, eGFR, and potassium in 4 weeks, then every 3 to 6 months. A small early drop in eGFR after starting empagliflozin is expected and isn’t a reason to stop it. Halve the metformin dose if eGFR falls below 45. Stop ibuprofen; acetaminophen up to 3 g a day and diclofenac gel for her knee. If albumin stays raised at 6 months, discuss adding finerenone. Refer to nephrology if eGFR falls below 30 or drops quickly. Cholesterol: LDL 1.9 mmol/L (73 mg/dL) on atorvastatin 40 mg; no change.
Her actions: home blood pressure twice a day for the 7 days before each nurse call; fasting glucose 3 mornings a week; walk 20 minutes on 4 days a week, building to 30; no more ibuprofen or other anti-inflammatory tablets from the pharmacy shelf. Education, checked by teach-back: what empagliflozin does; washing to prevent genital yeast infections; stopping it 3 days before any planned surgery; and sick-day rules: on days with vomiting, diarrhea, or not eating or drinking, pause empagliflozin, metformin, and lisinopril, restart once eating and drinking normally, and call the nurse if still unwell after a day. Sick-day card given. Referred to a diabetes education program, a dietitian for a kidney-friendly eating plan, and physiotherapy for knee strength. The pharmacist confirmed her drug plan covers empagliflozin.
Family physician: leads the plan and the medication changes; reviews in February and May. Practice nurse: phones monthly to go over home readings, side effects, sick days, and the walking goal; tells the physician the same day about home readings above 160/100. Clinic pharmacist: medication review in 2 weeks, checks she has stopped ibuprofen, and updates her pill organizer. Care coordinator: books the retinal exam, dietitian, diabetes education, and physiotherapy, and sends reminders for blood tests. Patient: the actions above, and brings her readings to every contact. Husband: comes to the dietitian visit and helps with the evening tablet alarm.
Green: home blood pressure mostly below 140/90, fasting glucose 5 to 8 mmol/L (90 to 144 mg/dL), feeling well. Keep to the plan. Yellow: vomiting, diarrhea, or unable to eat or drink; fasting glucose above 14 mmol/L (252 mg/dL) twice in a row; home blood pressure above 160/100 twice; burning when passing urine or genital itching. Follow the sick-day rules and call the clinic the same day. Red: nausea, vomiting, stomach pain, fast or deep breathing, or unusual drowsiness, even if her glucose is normal, which can be ketoacidosis; chest pain or weakness on one side; blood pressure 180/120 or higher with headache or confusion. Call 911. After hours: the clinic’s after-hours line, printed on the plan.
Nurse phone call on the first Tuesday of each month, with the last 7 days of home readings sent through the patient portal the day before. Tests: creatinine, eGFR, and potassium in 4 weeks; A1c in February; urine albumin and eGFR in May. Physician review in February 2027; full plan review in May 2027, or sooner after any emergency visit or hospital stay. Plan read through with her and her husband; she agreed to it and to sharing it with the pharmacist, dietitian, and diabetes education program. Printed copy given, and a copy posted to her portal.
Primary care, home visit 6 days after a hospital stay, with his daughter and the home care nurse
72-year-old man, widowed, lives alone in a ground-floor apartment. Home 6 days after 5 days in hospital with heart failure and fluid overload, his second admission this year. “I want to stay in my own place, and I don’t want to go back in.” Wants to walk to the corner café to meet his friends on Saturdays. Barriers: lives alone, mixes up his water pills, no car, and hearing loss with hearing aids. His daughter lives 20 minutes away and has agreed to be his caregiver contact. He would want hospital treatment but not a breathing machine; he named his daughter to decide for him if he can’t, and they will finish his advance care plan at a visit in 2 weeks.
1. Heart failure with reduced ejection fraction: ejection fraction 35% on echo in March 2026. Worsening, with 2 admissions this year; no swelling today. Breathless walking about 100 m on the flat. 2. COPD: post-bronchodilator FEV1/FVC 0.58, FEV1 48% predicted. One flare treated at home in July. COPD Assessment Test (CAT) score 22. Other issues: former smoker, 50 pack-years, quit 8 years ago; hearing loss; trouble keeping track of pills since his wife died. Allergy: penicillin, rash. Today: BP 112/68, HR 74, SpO2 93% on room air, weight 76.2 kg (168 lb). At discharge: potassium 4.8 mmol/L, creatinine 115 µmol/L (1.3 mg/dL), eGFR 58. Medications reconciled against the discharge summary and pharmacy: sacubitril/valsartan 49/51 mg twice daily, bisoprolol 2.5 mg daily, spironolactone 12.5 mg daily, dapagliflozin 10 mg daily, furosemide 40 mg each morning, tiotropium/olodaterol 2.5/2.5 mcg 2 puffs once daily, and albuterol (salbutamol) 2 puffs as needed. An old box of furosemide 20 mg tablets was found in the kitchen and removed with his agreement.
Weight: stay within 1 kg (2 lb) of his discharge weight of 76 kg (168 lb). Hospital stays: none in the next 6 months. Heart failure medicines: bisoprolol and sacubitril/valsartan raised to target doses, or the highest he tolerates, by March 2027. COPD symptoms: CAT 22 now; below 18 by March 2027. His own measure: walk to the café, about 400 m, with one rest, by the end of pulmonary rehabilitation in March 2027.
Heart failure: furosemide 40 mg each morning; potassium, sodium, and creatinine in 1 week and after each dose change. The heart failure clinic leads dose changes every 2 to 4 weeks, as heart rate, blood pressure, potassium, and kidney function allow; first clinic visit in 2 weeks. Bisoprolol is cardioselective and suits his COPD. COPD: continue tiotropium/olodaterol daily; spacer given for the rescue inhaler, technique taught back correctly. Standby course at home: prednisone 40 mg daily for 5 days and doxycycline, chosen for his penicillin allergy, to start after a call with the clinic. Prednisone can cause fluid retention, so weigh daily while taking it. Referred to pulmonary rehabilitation, with the heart failure clinic’s agreement. Influenza vaccine given in hospital; pneumococcal vaccine up to date; COVID-19 and RSV vaccines offered at the 4-week visit, per current guidance. SpO2 93% at rest: no home oxygen needed. Medication safety: weekly blister packs from his pharmacy from now on.
His actions: weigh every morning after the toilet and before breakfast, on the same scale, and write it on the chart on the fridge; take his pills from the blister pack; use the rescue inhaler with the spacer; walk around the apartment for 5 minutes 3 times a day until rehabilitation starts; cut down on salty foods such as canned soup and deli meat. Education, checked by teach-back with his daughter present: the weight and breathing zones below, how a heart failure flare differs from a COPD flare, and inhaler technique. Community services arranged: home care nurse weekly for 6 weeks; home care worker twice a week for showering and laundry; low-salt meal delivery 5 days a week; a medical alert pendant; a volunteer driver program for appointments; and the Saturday group at his local seniors’ center.
Family physician: leads the plan; home visit today, office review at 4 weeks; keeps in touch with the heart failure clinic. Practice nurse: phones weekly for 4 weeks, then every 2 weeks, about weight, breathing, and pills. Heart failure clinic: dose changes and blood test results, every 2 to 4 weeks. Pharmacist: weekly blister packs, and checks every change against the current list. Home care nurse: weekly visit to check weight, swelling, chest, and the blister pack; sends the weight chart to the practice nurse. Care coordinator: arranged home care, meals, the pendant, rehabilitation, and transport; the single contact for his daughter. Patient: weighs daily, takes the blister pack, and calls in the yellow zone. Daughter, caregiver: visits on Mondays, Wednesdays, and Fridays, checks the weight chart, and joins the 2-week visit; second contact on the plan.
Green: weight within 1 kg of 76 kg, usual breathlessness, sputum clear or white. Keep to the plan. Yellow, heart failure: weight up more than 1 kg (2 lb) in a day or 2 kg (4 lb) in a week, more ankle swelling, or needing more pillows to sleep. Take one extra furosemide 40 mg tablet that afternoon and call the clinic the same day. Yellow, COPD: more breathless, more sputum, or sputum turning yellow or green for more than a day. Use the rescue inhaler up to every 4 hours and call the clinic the same day about the standby course. Not sure which: call the clinic. Red: breathless at rest or unable to finish a sentence, chest pain, fainting, blue lips, or new confusion. Press the pendant or call 911. After hours: the nurse line on the fridge chart.
Practice nurse calls every Monday for 4 weeks, then every 2 weeks. The home care nurse sends the weekly weight chart through the portal; his daughter can call the care coordinator directly. Blood tests in 1 week and after each dose change. Advance care planning visit with his daughter in 2 weeks; office review at 4 weeks; full plan review in February 2027, or sooner after any emergency visit or hospital stay. Plan agreed with him and his daughter, with consent to share it with the heart failure clinic, home care, and pharmacy. Printed copy with the zones taped to his fridge; copies to his daughter, home care, and the heart failure clinic.
The patient’s priorities and goals, in their own words. The rest of the plan should serve them.
Avoid: Starting with your clinical targets. Patients follow a plan built around what they want to keep doing.
Every long-term condition, with where it stands today, so anyone on the team sees the whole picture.
Avoid: A list copied from the chart with no status. “Diabetes” tells the team less than “Diabetes, A1c 8.4%, not at target.”
Measurable targets, each with today’s value and a date, so the review can say whether it was met.
Avoid: Targets set without the patient. Agree each one, and note when it differs from the usual target, and why.
What will be done for each condition: medicines, monitoring, and referrals, with the reason for each change.
Avoid: Plans that clash across conditions. Check each change against the others, such as an anti-inflammatory for knee pain in someone with kidney disease.
What the patient will do between visits, the support they get to do it, and the services around them.
Avoid: Handing over leaflets with no check. Ask the patient to explain the plan back in their own words.
Who does what, by name, so every task has an owner and the patient knows who to call.
Avoid: Leaving out the patient and caregiver. They do most of the work between visits, so write their tasks down too.
What to do if things get worse, in zones the patient can follow at home.
Avoid: Vague triggers like “feeling worse.” Give the numbers: a weight gain, a home reading, a symptom that lasts more than a day.
How the team stays in touch between visits, when the plan is reviewed, and the patient’s agreement to it.
Avoid: A review date with nothing behind it. Book it, order the tests before it, and name who checks progress.
A plan written around your targets alone rarely survives the first month. Start with what the patient wants, and link each target to it.
“Improve blood pressure” can’t be reviewed. Write today’s value, the target, and when you expect to reach it.
“Monitor kidney function” needs a name: who orders the test, who reads the result, and who calls the patient.
Discharge often changes medicines and goals. Reconcile the list, check the action plan, and update the care plan within days, not at the next yearly review.
If the patient, caregiver, home care, and pharmacist don’t have the current plan, they work from memory. Give out copies, and note who has one.
Vero Scribe writes the care plan in your template from the planning visit, with the patient’s consent, or from your dictation. You review and edit every section, then copy it into your record or export it to Word or PDF. Vero works in 60+ languages.
The patient’s goals, a problem list with each condition’s status, measurable targets with dates, the plan for each condition, self-management support, who does what on the care team, community services, an action plan for flare-ups, check-ins between visits, the review date, and the patient’s agreement and copy.
A nursing care plan is built around nursing diagnoses, usually for a hospital stay or an episode of care. A visit note records one review. A chronic care plan is the primary care team’s shared plan for long-term conditions: it carries the goals, targets, and roles from visit to visit, and each follow-up note checks progress against it.
At least once a year, and sooner after a hospital stay, a new diagnosis, or a missed target. Many teams check progress every 3 months while treatment is changing. Contact between visits, such as monthly nurse calls, is part of the plan itself.
Some insurers’ care management programs do. They often ask for a written plan that covers every chronic condition, is agreed with the patient, gives them a copy, and is reviewed at set intervals. This template has those parts; check your program’s own list where you practice.
Yes. Copy it, or download it as a Word or text file. No account needed.
The preventive visit: interval history, screening and vaccines due, full exam, and counseling.
The Medicare AWV, G0438 and G0439: health risk assessment, cognition, screening schedule, risk factors, and the prevention plan.
The one-time IPPE, G0402: history, depression and safety review, exam with visual acuity, end-of-life planning, and the written plan.
The standing summary at the front of the chart: problems, history, medications, allergies, immunizations, risks, and reminders, kept current.
Screening, vaccines, and counselling due at an adult periodic health review, by age and sex, with a next due date on every line.
An initial plan and a worked follow-up review, linking goals to actions.
Outreach notes, home care handoffs, and patient recaps.
The visit note for each review: control, adherence, and the plan.
Notes, documents, and follow-up in one workspace.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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