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Talk:Care Plan Topic project

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Revision as of 09:18, 7 April 2010 by AnnekeGoossen (talk | contribs)
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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 contextuel definition. For a structural definition we can analyse the different steps disciplines use in the care process.

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 condiitons 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
  • Formulate a Plan for Actions
  • Develop a Agenda
  • Implement
  • Evaluate Care and Support
  • Generate Reports


Definitions of the different parts of the care plan

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