How to Write a Medication Care Plan
A medication care plan should document the support a person needs around prescribed medicines, their preferences and the observations or escalation relevant to safe administration.
What to include
- Level of independence with medication
- How medicines are administered within the service
- Allergies and known sensitivities where documented
- Preferences and communication around medicines
- Monitoring required by the prescribed plan or service procedure
- What to do if medication is refused, omitted or a concern is identified
Writing the care need
Describe the person's current ability and the support they require. Include relevant preferences and risks, but avoid generic statements that could apply to anybody.
Writing the outcome
Make the outcome meaningful to the person — for example maintaining independence, communicating needs, remaining comfortable, reducing avoidable risk or receiving consistent support.
Writing the care actions
State what staff should do in practical terms: level of assistance, approach, equipment, prompts, observations and escalation where relevant.
Review and update
Check the plan whenever the person's needs, abilities, risks, equipment or professional guidance changes, and follow the care provider's own review process.