Care Plan Glossary

return to: Patient Care

return to: Care Plan Topic project

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

Definition of Care Plan

Option 1:

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 2:

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

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.

Option 3:

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.

Option 4:

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.

Question; Beside diagnosis also include problem?

Definition of a Health Asset

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.

Another option: (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

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.

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.  

Option 1:

A definition 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.

Definition of Diagnosis

Option 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.

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.