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Assignment questions
NursingResearch paperCare coordination

Comprehensive Patient Needs Assessment Guide

The criteria ask for gaps and for a strategy to get the data you do not have. A thorough history that identifies no gap has not met either.

Editorial process

Last reviewed · August 16, 2026

01

A needs assessment is not a history, and gaps are the deliverable

The assessment criteria are unusually explicit and they name two outputs that a conventional history does not produce. The first is current gaps in the patient's care — not the patient's problems, which is a different list, but the places where care that should be happening is not: a medication reconciled nowhere, a specialist referral never closed, a follow-up appointment nobody owns, a self-management task the patient cannot perform and nobody has noticed. The second is a strategy for gathering assessment data not readily available from an initial patient interview, which means the paper has to plan for what it does not know. That is the criterion drafts skip, and it is the one that distinguishes care coordination from assessment: the coordinator's whole job is assembling a picture that no single encounter contains. Read those two criteria before you write and treat them as the paper's spine.

So write the second half as a data acquisition plan with sources named. Pharmacy dispensing records reveal adherence that self-report does not. A home visit or a video walkthrough shows the environment. A caregiver interview supplies what the patient cannot or will not say, and its absence is itself a finding. Records from other providers close the referral loops. Claims or utilisation data show where the patient has actually been. For each source, say what it would tell you, what consent or release it requires, and what you would do if it were unavailable — because a plan that assumes access will be granted is not a plan. Then connect the whole thing to the evidence: care coordination is a recognised national strategy for safety and quality, so ground the argument in that literature rather than in the assertion that coordination is good, and note the framing report the assessment supplies without treating a 2000 document as the current position.

Likely learning objectives

Inferred from the brief — check these against your own rubric.

  • 01
    Distinguish gaps in care from a list of patient problems.
  • 02
    Plan for information a single interview cannot provide.
  • 03
    Name data sources with their access requirements.
  • 04
    Ground the argument in care coordination evidence rather than assertion.
Assignment instructionsQuoted verbatim

Read the full question

Review every instruction before using the planning guidance that follows.

Complete an interactive simulation exploring the role of the nurse in health care coordination. Then, complete a comprehensive patient needs assessment of 4–5 pages. Note: Each assessment in this course builds on your work in the preceding assessment; therefore, complete the assessments in the order in which they are presented. Care coordination is an emerging and complex field in the health care system because of the growing number of providers, the various settings of care, and the numerous methods of delivering care. Hospitals are implementing several interventions to address gaps in care coordination, such as enhanced systems of communication, information technology, and personnel resourcing. This assessment provides an opportunity for you to complete a comprehensive needs assessment. By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria: •Competency 1: Determine the influence of current health care legislation, policy, and research on evidence-based practice in assessment by care coordinators. ◦Identify current gaps in a patient’s care. ◦Develop a strategy for gathering additional necessary assessment data not readily available from an initial patient interview. •Competency 2: Evaluate current factors (such as population health, cost, interprofessional communications) affecting patient outcomes related to care coordination. ◦Identify factors most likely to affect patient outcomes. ◦Advocate for the benefits of a multidisciplinary approach to patient care that a care coordination plan would foster. •Competency 3: Determine appropriate care coordination performance measures for driving high-quality patient outcomes, based on current accrediting standards and benchmarks. ◦Identify specific patient and care coordination outcome measures related to specific accrediting standards. •Competency 4: Apply relevant evidence-based practices that reflect a shift toward a broader population health focus on patient outcomes. ◦Identify evidence-based practices from the literature necessary to successfully implement a plan of care. •Competency 5: Communicate effectively with diverse audiences, in an appropriate form and style, consistent with applicable organizational, professional, and scholarly standards. ◦Write clearly and concisely, using correct grammar and mechanics. ◦Support main points, claims, and conclusions with credible evidence, correctly formatting citations and references using APA style. Context: In their book To Err Is Human: Building a Safer Health System, Kohn, Corrigan, and Donaldson (2000) identified collaborative communication and the reduction of medical errors as top priorities to improve the quality and safety of patient care. In response to this, the National Quality Forum (NQF), a nonprofit organization that works to catalyze improvements in health care, identified care coordination as an important national strategy to improve patient safety and quality of care delivery. Coordination of care supports patient safety and quality and is a recognized professional standard shared by registered nurses regardless of their practice setting. Whether educating a patient about his or her medication and plan of care, or reviewing follow-up care, nurses are essential in facilitating the continuity of care for all patients. Historically, nurses have engaged in coordinating care for every one of their patients. As the landscape of health care evolves, so does care coordination. Reference Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.). (2000). To err is human: Building a safer health system. Washington, DC: National Academies Press. Retrieved from http://www.nap.edu/openbook.php?record_id=9728 Questions to consider: As you prepare to complete this assessment, you may want to think about other related issues to deepen your understanding or broaden your viewpoint. You are encouraged to consider the questions below and discuss them with a fellow learner, a work associate, an interested friend, or a member of your professional community. Note that these questions are for your own development and exploration and do not need to be completed or submitted as part of your assessment. •What are the key reasons for completing a patient needs assessment? •Which types of information are likely to be most valuable for improving patient outcomes? •What are the benefits of a multidisciplinary approach to coordinated care?
02

Turn the brief into deliverables

  1. 01
    Identified gaps in the patient's current care.
  2. 02
    A strategy for gathering additional assessment data.
  3. 03
    Named sources with what each would reveal.
  4. 04
    Consent or access requirements for each source.
  5. 05
    A contingency where a source is unavailable.
  6. 06
    4-5 pages with credible evidence in APA format.
03

Current gaps, the missing data, then the strategy for getting it

01

The patient and the coordination question

Frame the case as a coordination problem rather than a clinical one.

02

Current gaps in care

Identify where care that should exist does not.

03

What the interview could not tell you

Name the limits of self-report and single-encounter assessment.

04

The data-gathering strategy

Name sources, what each reveals, and what access it needs.

05

Contingencies

Say what you would do if a source were refused or unavailable.

06

Evidence for the plan

Ground the approach in care coordination literature.

04

Care coordination evidence and the competencies behind it

Recommended databases

  • Agency for Healthcare Research and Quality
  • PubMed Central
  • National Quality Forum
  • Capella library resources

Search sequence

  1. 1.
    Complete the simulation first; the gaps it exposes are the paper's material.
  2. 2.
    Search for care coordination evidence rather than definitions.
  3. 3.
    Look up the discharge and transition toolkits for concrete data sources.
  4. 4.
    Check the date of any framing statistic before quoting it.
05

Reference shortlist

These are authoritative starting points, not a ready-made bibliography. A qualified reviewer must confirm that each source fits the assignment and supports the claim beside which it is cited.

Nothing here is cleared for citation until you have read it.

  1. 01

    Re-Engineered Discharge (RED) Toolkit

    Agency for Healthcare Research and Quality · 2024

    A worked toolkit for the transition data a coordinator has to assemble.

  2. 02

    Function of the Medical Team Quarterback: Patient, Family, and Physician Perspectives on Team Care Coordination in Patient- and Family-Centered Primary Care

    Journal of Patient Experience · 2019

    Patient, family and physician perspectives on who coordinates — the gaps, evidenced.

  3. 03

    Evidence-based modelling and taxonomy of hospital-based cancer care coordination nurses' roles and boundaries

    BMJ Oncology · 2025

    A taxonomy of coordination roles and boundaries, useful for defining what a gap is.

  4. 04

    COLLABORATION WITHIN THE INTERPROFESSIONAL TEAM

    Nursing Management and Professional Concepts, NCBI Bookshelf · 2022

    Interprofessional collaboration, for the sources beyond the patient.

  5. 05

    Health Literacy

    MedlinePlus, National Library of Medicine · 2025

    Why a self-management task may go undone without anyone recording a problem.

06

Review before submission

Common mistakes

  • Writing a thorough history that identifies no gaps.
  • Listing the patient's diagnoses instead of the gaps in their care.
  • Omitting the data-gathering strategy, which is a named criterion.
  • Assuming access to records without addressing consent.

Submission checklist

  • Have you named gaps rather than problems?
  • Does the data strategy name specific sources?
  • Is consent or release addressed for each?
  • Is there a contingency if a source is unavailable?

Use this guide to plan and review your own work. Follow your institution's rules and read our academic-integrity policy.

Written by

Aaron Bishop

MA, Education

assignment interpretation and research-methods coaching across disciplines

Aaron leads the EssayCrackers editorial desk. He works on how assignment briefs are read — what a rubric is actually asking for, and where students most often answer a different question than the one set.

Reviewed by

Dr. Nathan Cole

PhD, Rhetoric & Composition

Argumentation and thesis development

Nathan teaches first-year composition and directs a university writing center. He reviews EssayCrackers guides for argumentative soundness and citation accuracy.

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