Care plans in the real world

I would suggest that most, if not all of the pre-existing data stays where it is and we link to it/cite or reference it as necessary. From my POV the care plan contains the plan - the goals & targets plus the order/action pairs.

  • Goals & targets are updated over time as a result of test results, measurements, consultations etc.
  • The list of order/action pairs is updated as orders are completed…

We need to discuss what we mean by a care plan. Is there a single ‘master’ from a patient POV, which may include ‘sub plans’ eg immunisation plan (which could kickstart an infant’s record), diabetes management plan. There is a need to see all outstanding goals/orders/actions in order to do appropriate care coordination eg to ensure that a BP measurement required in 4 weeks time for the diabetes sub plan and another BP measurement due in 6 weeks for the hypertension sub plan is done at the same visit in 5 weeks by their GP to prevent duplication and two 3 hour round trips on public transport etc.

How to display all that is planned for those who need to see everything, yet filter it so that role-based activities are highlighted or read only in others. Plus all the shades of grey in between re views and permissions to add, update or modify.

It is super complex, but unless we have some kind of common approach, us modellers are guessing what is required for implementation.

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