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| | return to: [[Care Plan Topic project]] | | return to: [[Care Plan Topic project]] |
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| | + | further to: [[Care Plan Components]] |
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| | '''Current Activity:''' | | '''Current Activity:''' |
| − | Definining all the terms that are used in the Care Plan Topic.
| + | This has been removed to the Patient Care Glossary as a whole, still handling only the care plan examples at the moment. |
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| − | =Definition of Care Plan=
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| − | Option 1:
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| − | the definition of Care Plan from the ISO 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.
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| − | PCWG:
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| − | 1.The original CEN standard can be obtained from CEN (paid)
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| − | 2.The current working draft materials can be distributed once there is a document.
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| − | '''Concept''': care plan and health care plan
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| − | '''Definition''': duly personalised statement of planned health care activities bundles encompassing all foreseen health care
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| − | provider activities to be performed by one health care professional, or by several health care professionals having
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| − | the same health care professional entitlement
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| − | NOTE 1 Since any health care activities, including of course health care provider activities, may address more
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| − | than one health issue or have more than one health care goal, so does any care plan.
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| − | NOTE 2 A care plan can be identical to the programme of care whenever only one health care professional applies
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| − | the programme of care. | |
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| − | NOTE 3 A care plan is a piece of sharable information (sharable data), and as such is notified in one or more
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| − | sharable data repositories, where it can be accessed to, according to access rules.
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| − | EXAMPLES A nurse's care plan.
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| − | A care plan for immunisation, for smoking cessation.
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| − | Component of:programme of care. Multiplicity:one
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| − | {| class="wikitable sortable" border="1" cellpadding="5" cellspacing="0"
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| − | |- style="background:#2f4f4f; color:white"
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| − | |width="200pt"|Features or related entities
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| − | |width="200pt"|Type (examples
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| − | |width="200pt"|Multiplicity
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| − | |established at date and time|| ||one
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| − | |planned start date and time|| ||one
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| − | |-
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| − | |actual start date and time|| ||one
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| − | |-
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| − | |performance status||postponed/ underway/ cancelled||one
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| − | |-
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| − | |planned interruption periods|| ||zero to many
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| − | |-
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| − | |actual interruption periods|| ||zero to many
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| − | |}
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| − |
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| − | {| class="wikitable sortable" border="1" cellpadding="5" cellspacing="0"
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| − | |- style="background:#2f4f4f; color:white"
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| − | |width="200pt"|Direct relationship with
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| − | |width="200pt"|Name of relationship
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| − | |width="200pt"|Multiplicity
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| − | |health care professional||is applied by||one to many
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| − | |health issue||addresses||one to many
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| − | |health care goal||is subtended by||one to many
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| − | |health care provider activity||plans||one to many
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| − | |health care activities bundle||describes||one to many
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| − | |professional health record||is recorded in||one to many
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| − | |-
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| − | |sharable data repository||is notified in||zero to many
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| − | |}
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| − | UML representation to be added
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| − | Option 2:
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| − | Care Plan:'plan, based on data gathered during (subject of care) assessment, that identifies the care needs, lists the strategy for providing services to meet those needs, documents treatment goals and objectives, outlines the criteria for terminating specified interventions, and documents the (subject of care's) progress in meeting specified goals and objectives (Candidate)'. Definition from the skmt Glossary http://www.skmtglossary.org
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| − | Examples of the structure of the care plan
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| − | '''Example 1''' (Vereniging Gehandicaptenzorg Nederland, Requirements for an EHR,Utrecht, VGN)(Association for care of Disabled persons in the Netherlands)
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| − | *''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.
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| − | *''Formulate a Plan for Care and Support'': based on a structured framework, for example the framework of Shalock.
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| − | *''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.
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| − | *''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.
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| − | *''Implement'': giving care and support and register this in the EHR.
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| − | *''Evaluate Care and Support'': interpretation of the qualitative and quantitative information coming out of the process of care and support.
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| − | *''Generate Reports'': adjustment of the plan of care and support, plan for actions and the stage of implementation based on the evaluation.
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| − | =Definition of a Health Asset=
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| − | Patient Care Proposed Definition (adopted from openEHR Clinical Knowledge Manager definition of its antonym: problem)
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| − | An issue which is perceived to actually or potentially impact favourably on the physical, mental and/or social well-being of an individual.
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| − | Note: An issue may be perceived as an asset by one person but not so, or even as a problem, by another.
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| − | =Definition of Problem=
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| − | Patient Care Proposed Definition (adopted from openEHR Clinical Knowledge Manager definition)
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| − | An issue which is perceived to actually or potentially impact adversely on the physical, mental and/or social well-being of an individual.
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| − | Note: An issue may be perceived as a problem by one person but not so, or even as ahealth asset, by another.
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| − | From openEHR Clinical Knowledge Manager:
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| − | An issue or obstacle which adversely impacts on the physical, mental and/or social well-being of an individual. The definition of a problem is deliberately kept rather loose so as to capture any real or perceived concerns that may adversely affect an individual's wellbeing to any degree.
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| − | Option 1:
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| − | A definition from the HL7 Glossary:
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| − | A problem of a given individual can be described by formal diagnosis coding systems (such as DRG’s, NANDA Nursing Diagnosis, ICD9, DSM, etc.) or by other professional descriptions of health care issues
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| − | affecting an individual. Problems can be short or long term in nature, chronic or acute, and have a status. In a longitudinal record, all problems may be of importance in the overall long term care of an individual, and may undergo changes in status repeatedly. Problems are identified during patient visits, and may span multiple visits, encounters, or episodes of care.
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| − | =Definition of Diagnosis=
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| − | Option 1:
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| − | From the Clinical Knowledge Manager of openEHR:
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| − | A diagnosis defined by a clinician which is coded in an accepted terminology and may include the stage of the condition and the diagnostic criteria.
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