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Baseline Care Plan

(2 Pages)


On November 28, 2017, the Baseline Care Plan became one of the new requirements. Care plans can paint a plethora of a resident's data but what do we really need to have in the Baseline Care Plans? What are the required information on this specific form? The Baseline Care Plan provided here is a guide showing the MINIMUM required based on the SOM: State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities Table of Contents (Rev. 11-22-17). Sample goals in quotations are directly from the SOM to kick-off this person-centered form and to remind the clinician that the layman's language should be incorporated in the care plan.


Actual form will not have the large logo watermark.  Images are for sample viewing only.


Form is a 4-page DOCX file YOU CAN EDIT.


After card payment is processed, download button will appear on the Thank You page. 


This is a digital download. If unable to open file, a different format will be emailed within the next business day.  Sorry, no refunds because this is a digital format.



Baseline Care Plan Form

  • 4-page DOCX file.

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