Care Plan Glossary

return to: Patient Care

return to: Care Plan Topic project

further to: Care Plan Components

Current Activity: Definining all the terms that are used in the Care Plan Topic.

Procedure

The following procedure will be used:

1. What is the definition in the HL7 Glossary?

2. What is the definition in the skmt Glossary?

3. Is there a definition in a Draft ISO standard?

4. Is there an other definition that we can use?

5. Conference call on the definition

Definition of Care Plan

In the ballot of HL7, Universal domain, Care Provision, Care Plan Topic, 5.2.1 A_CarePlan (REPC_RM000200UV01, the following is described on the care plan:

"The term Patient Care Planning in MESH is described as:

Usually a written medical and nursing care program designed for a particular patient. Year introduced: 1968"

The basic theory underlying this structure comes from Larry Weeds Problem-oriented Medical Record, also introduced in the 1960s, which is used by many health professions and electronic health record systems as a primary method for organizing work and documentation."

Comments on that are: medical and nursing is not broad enough, Patient Care decided that the care paln topic is about a more abstract/ generic form af the care plan.

Question in this project is: "is definition of care plan in the ballot of HL7 a right definition for the purpose of this project?

Other definition are:

Option 1:from the HL7 glossary

Definition from the HL7 glossary (foundation)sourced from EHRS-FM:

A record of expected or planned activities, including observations, goals, services, appointments and procedures, usually organized in phases or sessions, which have the objective of organizing and managing health care activity for the patient, often focused upon one or more of the patient’s health care problems. Care plans may include order sets as actionable elements, usually supporting a single session or phase. Also known as Treatment Plan.

Option 2: from the skmt glossary

Definition from the skmt Glossary http://www.skmtglossary.org

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)'. Examples of the structure of the care plan

Option 3: from an draft ISO standard

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.

PCWG: 1.The original CEN standard can be obtained from CEN (paid) 2.The current working draft materials can be distributed once there is a document.

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

Option 4:Other definitions

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:

In a Dutch guideline for recording nursing data a nursing care plan is defined as a document with the following content:

• the nursing diagnosis of the patient;
• the nursing interventions that come out of the nursing diagnosis;
• the expected outcomes on which both the patient or his representive and the nurse agreed on;
• the period in which the expected outcomes much be obtained;
• review of the expected outcomes and if they are obtained;
• which nurse is going to carry out the nursing care plan;

For every nursing diagnosis the expected outcomes and the nursing interventions that belong to them are described. If there are interventions from other care professional are delegated tot the nurse, they will be integrated in the nursing care plan.

For a general definition of care plan it could be:

A care plan is defined as a document with the following content:

• the diagnosis of a patient;
• the interventions that come out of the diagnosis;
• the expected outcomes on which both the patient or his representive and the clinician agreed on;
• the period in which the expected outcomes much be obtained;
• review of the expected outcomes and if they are obtained;
• which clinician is going to carry out the nursing care plan;

For every diagnosis the expected outcomes and the interventions that belong to them are described. Interventions are multidisciplinary.

Definition of a Health Asset

Option 1:from the HL7 glossary

Option 2: from the skmt glossary

Option 3: from a draft ISO standard

Option 4: other definitions that we can consider

Example 1 from openEHR

Patient Care Proposed Definition (adopted from openEHR Clinical Knowledge Manager definition of its antonym: problem)

An issue which is perceived to actually or potentially  impact favourably on the physical, mental and/or social well-being of an individual.

Note: An issue may be perceived as an asset by one person but not so, or even as a problem, by another.

Example 2 from a Phd study: (Anneke prefere)

From: Rotegard, A.K., Moore, S.M., Fagermoen, M.S., Ruland, C.M.,(2009). Health assets: A concept analysis.International Journal of Nursing Studies,0020-7489 doi:10.1016/j.ijnurstu.2009.09.005

Health assets are the repertoire of potentials—internal and external strength qualities in the individual’s possession,both innate and acquired—that mobilize positive health behaviors and optimal health/wellness outcomes.

Definition of Problem

Option 1:from the HL7 glossary

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 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. Patient Care Proposed Definition (adopted from openEHR Clinical Knowledge Manager definition)

An issue which is perceived to actually or potentially  impact adversely  on the physical, mental and/or social well-being of an individual.

Note: An issue may be perceived as a problem by one person but not so, or even as ahealth asset, by another.

Option 2: from the skmt glossary

Option 3: from a draft ISO standard

Option 4: other definitions that we can use

Example 1: from openEHR Clinical Knowledge Manager

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.

Example 2: from the CCD document

(HL7 Implementation Guide: CDA Release 2 – Continuity of Care Document (CCD), april 2007)

A problem is a clinical statement that a clinician is particularly concerned about and wants to track. It has important patient management use cases (e.g. health records often present the problem list as a way of summarizing a patient's medical history).

Definition of Diagnosis

Option 1:from the HL7 glossary

Option 2:From the skmt glossary (Canada, infoway)

Identification of disease or condition by a practitioner by means of a person’s symptoms, diagnostic tests, etc.

Option 3: from a draft ISO standard From the the ISO EN 13940-1:2007 (continuity of care)

Outcome of the nosological knowledge-based assessment of a health condition by a health care professional.

NOTE 1 Establishing a diagnosis consists in discriminating between several candidate health conditions (diseases, injuries, etc.) and naming the most likely one or ones at the time of observation. The description of those candidate health conditions is part of the currently acknowledged professional knowledge embedded in a nosology, adequately reflected in an terminology, used to designate and name health conditions.

NOTE 2 A diagnosis is bound to a subject of care, an observer, a time of observation and a professional knowledge. With obvious exceptions --amputation of a part of the body-- by essence a diagnosis remains provisional and, to a certain extent, subjective.

Also mentioned the working diagnosis:diagnosis on which a health care process is based.

NOTE A working diagnosis may be disputed or contradicted during the health care process, possibly leading to its revision.

Option 4: other definitions that we can use

Example 1: from the Clinical Knowledge Manager of openEHR

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.

Example 2: from Sabacare (http://www.sabacare.com/Diagnoses/?PHPSESSID=43a91c74e6907cab71ce6ac127a899a3)

A nursing diagnosis is "a clinical judgment about individual, family, or community responses to actual or potential health problems/life processes. Nursing diagnoses provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable" (NANDA, 1992 p. 5). Nursing diagnoses are concepts used to describe actual and potential health problems of clients. They describe clinical nursing practice in a uniform manner.

Can this be made more general?

Definition of Health state?

Option 1:from the HL7 glossary

Option 2: from the skmt glossary

Option 3: from a draft ISO standard

Option 4: other definitions that we can consider

Example 1: from the the ISO EN 13940-1:2007 (continuity of care, part 2)

Composite state of a person’s physical and mental functions, body structure, activity, participation and environmental factors

NOTE A health state is an object, a perception of which is a health condition. A health state may possibly give way to more than one perception, resulting on more than one health conditions.

Note: UML representation available in the draft standard.

Definition of Health condition?

Option 1:from the HL7 glossary

Option 2: from the skmt glossary

Option 3: from a draft ISO standard

Option 4: other definitions that we can consider

Example 1: from the the ISO EN 13940-1:2007 (continuity of care, part 2)

Perception of one or more aspects of the health state of a person at a given time

NOTE 1 In the perspective of health care, the term 'health condition' is often used to label a bad condition (diseases, disorders, injuries, etc.), because it may then motivate certain health care activities

NOTE 2 A health state is an object, a perception of which is a health condition. The underlying health state is nevertheless present even if not perceived by an observer, possibly the subject of care her- or himself, e.g. a cancer before it gives symptoms.

NOTE 3 In a health care process, more particularly in a clinical process, the health state of the subject of care is the processed clinical object. The evolving health state along the process follows a life cycle and, along its successive steps, is perceived as different stages of the subject's of care health condition: initial, assessed, target, matched, resulting (the outcome of the process), evaluated.

NOTE 4 zero to one relationship with diagnosis (or is it 'health condition' that has this relationship, at any stage of its life cycle?)

EXAMPLES a diagnosis: an acute myocardial infarction; a symptom: a head ache.

Note: UML representation available in the draft standard.

Definition of Health issue?

Option 1:from the HL7 glossary

Option 2: from the skmt glossary

Option 3: from a draft ISO standard

Option 4: other definitions that we can consider

Example 1: from the the ISO EN 13940-1:2007 (continuity of care, part 1)

Issue related to the health of a subject of care, as identified or stated by a specific health care party.

Example 2: from openEHR (archetype issue presented by a person)

An issue, symptom, or complaint presented to the health provider seeking explanation, education, understanding, investigation or treatment

Definition of intervention

Option 1:from the HL7 glossary

Option 2: from the skmt glossary

Option 3: from a draft ISO standard

Option 4: other definitions that we can use

Example 1:

The act of intervening, interfering or interceding with the intent of modifying the outcome. In medicine, an intervention is usually undertaken to help treat or cure a condition.(http://www.medterms.com/script/main/art.asp?articlekey=34214)

Example 2:

A nursing intervention is defined as a single nursing action - treatment, procedure or activity - designed to achieve an outcome to a diagnosis, nursing or medical, for which the nurse is accountable (Saba, 2007).

Can this be made more general?