Talk:Care Plan Topic project

Definition of Care Plan

One of the deliverables in this project is a definition of Care Plan.A source is an ISO standard where the Care Plan is defined. The definition below comes from EN 13940-1:2007. This can be seen as the conceptual and contextual definition. For a structural definition we can analyse the different steps disciplines use in the care process.

Luigi: Can we have access to 13940-1:2007?

Luigi: Is our project focused on Nursing Plan of Care? This could be modeled as a type of Plan of Care. Consequently, we may have to re-state the ISO standard from a nursing perspective.

Questions for the work on the definition for care plan are:

• Can we live with the definition from the ISO standard? If no, which points of discussion are there in this definition?
• What are the different steps that the different disciplines in health care are using and can we come to a generic structure of the care plan?

Concept: care plan and health care plan

Definition: duly personalised statement of planned health care activities bundles encompassing all foreseen health care provider activities to be performed by one health care professional, or by several health care professionals having the same health care professional entitlement

NOTE 1 Since any health care activities, including of course health care provider activities, may address more than one health issue or have more than one health care goal, so does any care plan.

NOTE 2 A care plan can be identical to the programme of care whenever only one health care professional applies the programme of care.

NOTE 3 A care plan is a piece of sharable information (sharable data), and as such is notified in one or more sharable data repositories, where it can be accessed to, according to access rules.

EXAMPLES A nurse's care plan. A care plan for immunisation, for smoking cessation.

Component of:programme of care. Multiplicity:one

Features or related entities	Type (examples	Multiplicity
established at date and time		one
planned start date and time		one
actual start date and time		one
performance status	postponed/ underway/ cancelled	one
planned interruption periods		zero to many
actual interruption periods		zero to many

Direct relationship with	Name of relationship	Multiplicity
health care professional	is applied by	one to many
health issue	addresses	one to many
health care goal	is subtended by	one to many
health care provider activity	plans	one to many
health care activities bundle	describes	one to many
professional health record	is recorded in	one to many
sharable data repository	is notified in	zero to many

UML representation to be added

Examples of the structure of the care plan

Example 1 (Vereniging Gehandicaptenzorg Nederland, Requirements for an EHR,Utrecht, VGN)(Association for care of Disabled persons in the Netherlands)

• Formulate a Person Image: this stage gives support and directions on the stage of diagnosing by cathering information (current conditions and the history of care and support)about the client.The different scores and diagnoses will be registered in the EHR (assessment, physical examination, lab results, medication,therapies and aspects of behaviour).Starting point for this is a way of working where the care- and support goals are really related to the needs of the client.
• Formulate a Plan for Care and Support: based on a structured framework, for example the framework of Shalock.
• Formulate a Plan for Actions: the translation of the desired goals into concrete actions tuned to the capacity needs of the client.It gives the caregiver a relationship between the content of care and the financial system.
• Develop a Agenda:a timeframe for the actions that are planned.In the agenda the following is described:which action, where, when, by and with who, based on which protocol and issues.
• Implement: giving care and support and register this in the EHR.
• Evaluate Care and Support: interpretation of the qualitative and quantitative information coming out of the process of care and support.
• Generate Reports: adjustment of the plan of care and support, plan for actions and the stage of implementation based on the evaluation.

Example 2

Definitions of the different parts of the care plan

If we agree on the structural definition of the care plan what are the definitions of the several parts of the care plan? Example: what is the definition of diagnosis?

Review the following standard for a definition of diagnosis: ISO TS 22789 Health informatics – Conceptual framework for patient findings and problems in terminologies. The scope of clinical findings includes diseases and findings of state or function. Based on initial analysis, 18104 does not support representation of diseases (which can be designated as ‘medical’ diagnoses). It may support representation of some findings of state or function.