Care plans in the real world

[thomas.beale]

@heather.leslie

how I envisaged that a care plan might be constructed - as a single persistent list containing goals/targets and a collection of INSTRUCTION/ACTION pairs. The latest iteration has had that content removed as result of an Editorial decision to remove any constraints in templates as design guidance, but the intended build of a SECTION representing this content has not quite eventuated as planned.

Some technical thoughts…

First let’s assume a Care Plan roughly includes:

• Dx: primary diagnosis or problem (what the CP is there to address)
• Obs: supporting evidence: symptoms, labs, imaging, other investigations
• G: goals given Dx and patient specifics
• Pr: prognosis - outlook for the patient as things stand
• P: the main plan
  • R: recommendations - general description of approach, e.g. recommend lumpectomy + chemo + monitoring
  • O: orders
  • A: actions resulting from the orders
• M: Monitoring / follow-up plan
  • probably more orders, e.g. service requests.

Then we can think about what is directly included in the plan, and what is referenced (or ‘cited’) by the plan. Normally Observations and Dx are made before a plan - the plan is created as a result of the Dx. Goals and recommendations are usually authored as part of the plan. Orders (Instructions) could be part of the plan, or they might be created by someone else (junior docs, following the plan for example) and created separately. Actions resulting from the Orders almost certainly won’t be ‘in the plan’.

So a fair bit of the plan’s contents are references to pre-existing data (Dx, some Obs) and to-be-created data - possibly Orders, and certainly Actions.

So we need a proper citation mechanism to do this properly. We have discussed this at great length, and there are some mooted improvements to the RM to support it.

Under this idea, the Care Plan contains some primary content plus a lot of references to other content relevant to the plan - i.e. it is partially an index of other content, particularly Orders and Actions. Creating a new Order based on a Care Plan should cause a citation / ref to that Order to be added to the plan; same for Actions resulting from the Order.

So then an interesting question is: what does archetyping of all this look like? If we were to go with the VIEW_ENTRY approach, it’s quite easy, because your archetype contains VIEW_ENTRYs and they would be marked to be of a certain RM type or archetype - e.g. INSTRUCTION.service_request etc.