For most wounds, the overall aim will be healing by primary intention within a specified time frame but there may be some wounds that are allowed to heal by secondary intention and the treatment aim may be wound bed preparation, other intermediate aims which should also be recorded such as reduction in pain, odour etc.
\n ", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Care and support plan", "implamentationGuidance": "The wound care treatment plan uses the existing PRSB Personalised Care and Support Plan (PCSP) standard. Examples are available on the wound care information standard webpage (www.theprsb.org/standards/woundcare )
It should be possible to restrict access to the care and support plan in most cases based on the individual\u2019s consent\n preferences. However, a data controller may choose to release all or part of the record for legitimate reasons, for example when a person using services is unable to give consent.
It should be possible to add attachments or hyperlinks in care and support plans to provide guidance, learning materials, explanatory notes, etc. The date/time of the\n hyperlink/addition should be included.
It should be possible to add comments to the plan and to sections in the plan, for example. to identify progress towards a goal (which should have a formal mechanism associated for capturing information). It should also be possible to comment on actions undertaken or suggest changes to actions. Note that adding\n comments to a plan is not the same as having a dialogue with others involved in the care and support planning process. Separate functionality, e.g. secure messaging would be required for this.
", "description": "This records the decisions reached during conversation between the individual and health and care professional about future plans and also records progress.", "informationType": "Event.Record", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Strengths", "implamentationGuidance": "Definition:
Definition: Any strengths and assets the person has (i.e. things a person is good at or enjoys doing) relating to their goals and hopes about their health and wellbeing. For example, \u2018able to participate in leisure activities\u2019 such as a sport in order to improve health and wellbeing by losing\n weight. |
Needs are defined as health or care deficits identified by the person with their carer(s) or professionals and are the motivations/indications for healthcare activities. Examples of needs could be (e.g.) \u2018to dress myself\u2019; \u2018to better understand what my various medications are for\u2019; \u2018to reduce pain in my knees\u2019.
Concerns are gathered\n information to support continuity of care for a person. Concerns can include biological, psychological or social concerns. They may include things the person or carer is concerned about. For example, a person\u2019s concern may be \u2018the quality of social housing\u2019; a professional\u2019s concern could be \u2018high blood pressure
Problems are defined as: A condition that\n needs addressing and is important for every professional to know about when seeing a person. Problems may include diagnoses (e.g. COPD; diabetes), symptoms (e.g. joint pain; breathlessness), disabilities (e.g. sensory impairments; amputations), health, social and behavioural issues. Problems recorded here may link to the problem list held in a shared care record\n or GP system for a person using services.
Goals and hopes are defined as: The overall goals, hopes, aims or targets that the person has. Including anything that the person wants to achieve that relates to their future health and wellbeing. Each goal may include a description of why it is important to the person. Goals may also be ranked in order of\n importance or priority to the person. For example, \u2018weight loss\u2019; smoking cessation\u2019; \u2018reducing alcohol intake\u2019; \u2018increased sleep\u2019. \u2018Goals\u2019 tends to be historically a more medically-used term, whereas \u2018hopes\u2019 is used more widely in social care settings.
It should be possible to include tables (e.g. weekly schedule), diagrams or images (e.g. to illustrate\n how a person has made progress towards a goal) as well as video and audio clips (i.e. as a communication tool for individuals with complex accessibility requirements).
It should be possible to prioritise goals, indicating the importance of each goal to the person (e.g. a scale 1 to 10).
Each action may also have an associated additional indicator\n showing how confident the person is to carry it out (e.g. a scale from 1 to 10).
The care and support plan should be structured in a way that supports digital information exchange, with separate sections for strengths, needs and problems which can be linked to specific goals.
Of particular importance is the link between needs in a care plan and\n related goals. Each goal must link to specific needs, as well as any actions associated with it. Goals may also have related outcomes.
The sections associated with goals and actions that are the focus of specific care professionals should be interoperable with the care plan that professional uses for their day to day work
Updates to the care and\n support plan section may include:
Add, edit or archive strengths, needs, concerns or problems. If a strength/need/concern becomes more or less important, then goals may need to be changed, as will associated actions.
Add, edit or archive goals. When a goal is archived it should be possible to also archive the actions associated with\n it. If the actions are still valid it should be possible to attach them to another goal.
Add, edit or archive actions. Once an action has been completed (i.e. status updated to indicate it has been completed), it should be possible to archive it from the care and support plan. It should be removed from the current active view of the plan,\n but available to view in previous versions of the plan.
Recording outcomes related to goals. Once a goal has been achieved, it should be possible to archive it from the care and support plan, so that it is removed from the view of the current plan, but available to view in previous versions of the care and support\n plan.
Holds the target date and / or the frequency of the action and activities, this could either be a date / time or a description of the frequency, for example daily or weekly it could also be an unspecified value such as \"as needed\"
", "description": "Planned date, time, or interval, as relevant", "valueSets": "Date and time, or other representation of a time period
", "valueDomain": [{"type": "string"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Suggested strategies", "description": "Suggested strategies for potential problems.", "valueSets": "Free text.", "valueDomain": [{"type": "text"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Status", "description": "The status of the action or activity e.g. in progress, done, refused", "valueSets": "\nAgreement of the plan with the person (or representative) should be recorded. If agreement cannot be obtained the reason for this should be documented.
Where a person has been unable to agree, due to, for example, lacking mental capacity, actions should be undertaken to maximise capacity and the plan should demonstrate how a person\u2019s\n rights will be promoted. If a person is unable to consent, a mental capacity assessment should be attempted, and if there is no legal representative a best interest decision made.
", "description": "Indicates whether the plan was discussed and agreed with the person or legitimate representative.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person or legitimate representative", "description": "Indicates whether the plan was discussed and agreed with the person or legitimate representative", "valueSets": "Person or legitimate representative\u00a0", "valueDomain": [{"type": "boolean"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Person full name", "description": "The full name of the person in text representation.", "valueSets": "NHS data dictionary :- Person full name \n ", "valueDomain": [{"type": "string", "property": [{"maxLength": "70"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person.", "valueSets": "\nIn health and social care there may be different sources of funding (e.g. personal budget/personal health budgets) to meet the aims and goals of the person. The \u2018Care Funding Source\u2019 section should only detail the source of the funding so as to support easy resolution where a question about funding arises. The information should not include\n the details of the funding, which will be held in separate documents.
", "description": "A reference to the funding source and any conditions or limitations associated.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The organisation code of the care funding source", "valueSets": "NHS data dictionary : - organisation data service \n "}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "name": "Free text ", "description": "Any further information for the person's care funding source e.g. self funded", "valueSets": "Free text\u00a0", "valueDomain": [{"type": "text"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Date this plan was last updated", "implamentationGuidance": "This information should be automatically retrievable from the system.
", "description": "This is a record of the date that this care and support plan was last updated.", "valueSets": "Date and time", "valueDomain": [{"type": "datetime", "property": [{"timeStampPrecision": "YMDHM"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Other care planning documents", "description": "Reference other care planning documents, including the type, location and date.Escalation or contingency plans are known by many other terms depending on care setting and local implementations. Please see section 5 (see\u00a0Personalised-care-and-support-plan-Detailed-implementation-guidance-v2.8.pdf (theprsb.org)) for a non-exhaustive list of alternative terms for the sections of the personalised care and support plan.
Not everyone who has a care and support plan will need a contingency plan (also known as e.g. crisis / emergency / escalation plans \u2013 see Section 5\n (see\u00a0Personalised-care-and-support-plan-Detailed-implementation-guidance-v2.8.pdf (theprsb.org))\u00a0
This plan is for those people who have specific and predictable risks associated\n with their health and wellbeing. It describes how disruptions to the care and support plan should be addressed.
There may be a number of different contingency plans to manage different aspects of health and wellbeing, e.g. diabetes, respiratory, mental health, substance misuse, etc. The plan may cover different scenarios, e.g. mild disruption/issues,\n through to more severe.
It must be possible to create a contingency plan at any time when the individual and those providing care and support identify a need for such a plan.
Contingency plans must be subject to or as a result of an assessment.
Contingency plans may include end of life care planning elements. These only form part of an initial\n conversation and a full end of life care plan should be included separately as an end of life care document.
The \u2018Coping Strategies\u2019 element should include details of all coping strategies used in free text. Any tools used to carry out the coping strategy should be included here.
Coping strategies may need to be regularly updated as it may depend on\n the stage of recovery the person is at.
", "description": "Signs to watch out for that may indicate a significant change in health or other circumstances. These could include physical health conditions, environmental factors, or mental health problems, (e.g. feeling anxious)
", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The trigger that leads to instigation of\u00a0a significant change in health or other circumstances.The name of the contingency plan
", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for the type of contingency plan
", "valueSets": "The additional supporting plans should be used for the wound treatment plan, see examples on the PRSB wound care webpage www.theprsb.org/standards/woundcare
It must be possible to hold additional supporting plans, which may be linked to the care and support plan where the individual or care professional decides that the information\n should be available to others. Examples of additional supporting plans: asthma plan, mental health plan, tissue viability plan, nutrition plan, falls prevention plan, hospital or other service transfer of care plan, etc.
The format of additional supporting plans will vary according to the type of plan. Some may be structured and coded, some may include\n diagrams or images.
Additional supporting plans should be available for others to view, but will only be created, updated and ended by the service creating the plan. These may be made available on the National record Locator Service (NRL) in PDF format.
When an additional supporting plan is updated a new version of the plan may be linked to the care\n and support plan, again at the discretion of the individual or care professional.
Educational and health care plans are produced for people with neurodevelopmental conditions and apply up to the age of 25. However, they transition into adult services earlier so it is important to note that this plan may exist at the same time as a care and support\n plan.
", "description": "Additional support plans", "informationType": "Event.Record", "concept": [{"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Additional support plan name", "description": "The name of the particular additional supporting plan, e.g. dieticians plan, wound management plan, discharge management plan and behaviour support plan.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Coded value", "description": "The coded value for the type of contingency plan
", "valueSets": "For most wounds, the overall aim will be healing by primary intention within a specified time frame but there may be some wounds that are allowed to heal by secondary intention and the treatment aim may be wound bed preparation, other intermediate aims which should also be recorded such as reduction in pain, odour etc.
", "description": "This is the content of any additional care and support plan which the person and/or care professional consider should be shared with others providing care and support. May be structured in different ways, e.g. tables, diagrams, images. This is the content of any additional care and support plan which the individual and/or care professional consider should\n be shared with others providing care and support. It should be structured as recommended for the care and support plan and if contains additional detail, it may be referenced here.", "valueSets": "Free text", "valueDomain": [{"type": "text"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Planned review date/interval", "description": "This is the date/interval when this information will next be reviewed. SNOMED CT tag : -\u00a0425268008 | Review of care plan (procedure) |", "valueSets": "Date and time", "valueDomain": [{"type": "datetime"}]}, {"type": "group", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Responsibility for review", "description": "This is a record of who has responsibility for arranging review of this information. Should include their name, role and contact details.", "concept": [{"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Name", "description": "The name of the professional with responsibility for the care of the person.", "valueSets": "Free text", "valueDomain": [{"type": "text", "property": [{"maxLength": "70"}]}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "1", "mro": "R", "name": "Role", "description": "The role the professional has in relation to the person e.g. GP, physiotherapist, community nurse, social worker, key worker, care home manager, care coordinator, LA hospital liaison person, care home contact, hospital clinician, Independent Mental Capacity Advocate (IMCA) etc", "valueSets": "FHIR values set : -\u00a0 ukcorepractitionerrolecode \nPersonal preferences include any treatment objectives that the person (or their carer) may have for the episode of treatment. This may encompass, treatment outcome, or the use of specific wound care products. The preferences may be based on previous experience that the person has had with wound care products, equipment or\n treatments.
Carers preferences can also be reflected
If person has an \"About Me\" (PRSB Standard) then this should be considered as part of gathering their preferences
", "description": "\nPerson\u2019s and carer\u2019s priorities and expectations for treatment, these change over time, NB, person and carer\u2019s objectives may not be consistent, including practicalities, environmental and logistical considerations (transport etc.) These include
\nsocial preferences, for example being mobile for daughters wedding
\nstate of care preferences, for example, reduction of odour or visibility of dressings
\nexperience from previous treatments
\nprevious equipment experience
\nreferred communication method
\nExperience from the person's experience of treatment of similar conditions
\n ", "valueSets": "Free text
", "valueDomain": [{"type": "string"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Previous equipment experience", "description": "\nA persons experience of using equipment in similar conditions
\n ", "valueSets": "Free text
", "valueDomain": [{"type": "string"}]}, {"type": "item", "minimumMultiplicity": "0", "maximumMultiplicity": "*", "mro": "R", "name": "Third party preferences", "implamentationGuidance": "\nIn this context the third party is typically a carer, next of kin or other relative
\n ", "description": "\nPreferences and objectives relating to the treatment of the person, but are stated by a third party, such as next of kin, or carer
\n ", "valueSets": "Free text
", "valueDomain": [{"type": "string"}]}]}]}]}