Methods: A cross-sectional mixed-model study was conducted. Results of the comprehensive geriatric assessment were compared to the care plans to reveal the percentage of problems included. Semi-structured interviews were performed with 12 practice nurses who visited older people at home. Per practice nurse, care plans of 10 older people (total n = 120) were purposefully selected and discussed to identify reasons for not registering problems in the care plan and to determine whether and how problems were monitored.