The Care Process (Kaigo Katei): From Assessment to Evaluation

The care process（介護過程）· Material

介護過程の進め方 · Updated 26 October 2026

介護過程 is a systematic way of working in care: understand a person's life and wishes as a whole, draw up a plan, carry it out, then evaluate the results to improve the next round of support. The 介護過程 field tests whether we work according to this process rather than simply completing one care task after another.

The four stages of the care process

The first stage is gathering and analysing information （アセスメント）: collect data on physical and mental condition, daily life, life history, and the wishes of the person and their family, then analyse the real needs （ニーズ）. The second stage is drawing up the plan （計画立案）: set concrete long-term and short-term goals, together with the support needed to reach them.

The third stage is implementation （実施）: provide care according to the plan while observing the person's reactions and changes and recording them. The fourth stage is evaluation （評価）: compare the results with the goals — were they achieved, and what has changed — and use the findings for reassessment and revising the plan. The four stages turn in a cycle, not a one-way street.

• Order: アセスメント → 計画立案 → 実施 → 評価 → back to assessment
• Plan goals must be concrete: long-term and short-term

The ICF viewpoint: life functions

Good assessment uses the WHO's ICF framework （国際生活機能分類）. The ICF views life functions （生活機能） from three sides: body functions and structures （心身機能・身体構造）, activities （活動） such as eating and walking, and participation （参加） in society and social roles. All three are influenced by environmental factors （環境因子） — facilities, family, social attitudes — and personal factors （個人因子）.

As a result, staff look not only at "what the person cannot do" （障害）, but also at the strengths and abilities that remain （できること） and at environments that can be adjusted to support independence. This is the foundation of care aimed at 自立支援， rather than care that takes everything out of the user's hands.

• ICF: 心身機能・身体構造， 活動， 参加 + 環境因子・個人因子
• Focus on the abilities that remain, not only on deficits

How a ケアプラン differs from each service's plan

The ケアプラン (formally 居宅介護サービス計画） is drawn up by the care manager as an overall plan across services. Based on it, each service provider — for example a facility or a home-visit service — makes its own care plan （施設サービス計画 or 訪問介護計画）. The two must align: the service plan is the concrete elaboration of the ケアプラン for that provider's own area of work.

During implementation, monitoring （モニタリング） is carried out regularly: is the service running as planned, and have the user's needs changed? Monitoring findings are shared with the multidisciplinary team （多職種連携） — nurses, rehabilitation therapists, doctors, dietitians — because good care is never done by one profession alone.

• ケアプラン： the overall plan, by the care manager
• Each service's plan: an elaboration of the ケアプラン
• Regular モニタリング + information sharing across professions

Good record-keeping

Care records （介護記録） are part of the process, not a formality. Records must be factual and objective — write what was observed, not guesses — and be written immediately after the action so nothing is forgotten. Records serve to share information within the team, provide material for evaluation and plan improvement, and form professional accountability for the care given.

• Objective and factual, not personal interpretation
• Written immediately; used for evaluation and team coordination

Key terms

Frequently tested points

• The stage order is a classic question: assessment always comes first, and evaluation always leads back to the next assessment.
• Evaluation is not the end of the process — its results are used to improve the plan.
• The ICF assesses three elements: body functions and structures, activities, and participation; do not confuse it with a disease diagnosis.
• The ケアプラン is made by the care manager; facility/service plans are made by the provider based on that ケアプラン.

Independent study material for the Japanese national Certified Care Worker exam (介護福祉士国家試験). Official terms and rules may change — always cross-check with the latest official sources.