Excellent Practices

My care plan

Practice Category: Services

Centre: Karolinska Institute and University Hospital

Eva Jolly


Challenge which the practice addresses

The challenge was to secure that patients were involved, informed, and knew about the plan for their care throughout the care process.


The solution was to develop a digital care plan that includes information packages for all diagnoses.
The digital care plan is accessible for all involved professionals through the electronic patient record and includes a template for planning the patient’s individual treatment and care. This is drafted by the contact nurse in collaboration with the patient.

Examples of the content:

  • Contact information to physicians, contact nurse, counsellor and other important health care professionals.
  • Support, advice and arrangements during treatment and rehabilitation.
  • Different appointments for examinations and treatments and a description of when different examinations should take place.
  • Answers to practical questions and a description of self-care.
  • Information about the patient’s rights, for example the right to a second opinion
  • Distinct information on how the follow-up is planned, for example, who the patient should contact if they have questions.
  • The care plan after treatment also contains a summary of the care and what is important to think about regarding follow-up and continued rehabilitation.


More patients receive comprehensive information about treatment and side effects. Patients now also receive a written care plan that they can take with them.

The templates are documented through quality assessment follow-up on a regular basis. Patient satisfaction concerning information and participation in care planning is also followed through the quality assessment system.

We have assessed how the contact nurses perceived the use of the templates and identified areas for improvement.

Critical success factors

We have worked with designated champions (contact nurses and head nurses) to develop and implement this in clinical practice.

We have had several workshops with the contact nurses and the nursing leadership at the Karolinska CCC.

The directors of nursing development have ongoing responsibility for the implementation and further development of My Care Plan.

Next steps

To further develop patient involvement when the contact nurse is planning the patient’s treatment.
To support the contact nurses to be more focused in planning of the rehabilitation process for the patients.