Care Planning Guidance for Ardens Users Templates to support care planning

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Joel Little
5 years ago
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the person standing in front of a building icon under the patient

1 Care Planning Guidance for Ardens Users Templates to support care planning Step 1 Undertake a review of the patients conditions. 1.1 Open the LTC review template: You will find this by clicking on the person standing in front of a building icon under the patient details: You will now see this template: If you do not see this, click on the tab labelled review Ardens Care Plans Page 1 of 14 June 2017 v1

The first condition appears and you can click on start to complete the template.

2 1.2 Under take a review of each condition On the right-hand side of the template you will see this list: Click on Conditions and this will open up the review template for the first condition that your patient has. The first condition appears and you can click on start to complete the template. If you have completed this particular review recently, you can click skip to next to move onto the next condition. Ardens Care Plans Page 2 of 14 June 2017 v1

3 When you have clicked start a template like this will appear: You will notice that some fields have a star next to them. These are QoF fields. Recording information in these fields ensures you are capturing and coding the right information for your QoF points. You need to complete all (or as much as possible) of the template. At the bottom you will see a field called care plan: Click on the box New Diabetes Care Plan NB: For COPD this will be called New COPD Care Plan ; For Asthma it will say New Asthma care plan etc There may be some LTCs that don t have this field. The CCG is developing these. The care plan will open in a new word document. You will need to print this out and give it to the patient, as well as saving it into the patient s record. Ardens Care Plans Page 3 of 14 June 2017 v1

This will now open a word document: NB: These documents are not a complete care plan, although this is what

4 When you click on New Diabetes Care Plan the New letter form appears. Check the details are correct and click on Write Now. This will now open a word document: NB: These documents are not a complete care plan, although this is what Ardens has called them. These are supplements to support patients to self-manage their condition. These documents are part 1 of a comprehensive care plan. Ardens Care Plans Page 4 of 14 June 2017 v1

You will need to print this for the patient (Go to File-Print) and then save this to the patient record WARNING: When you save the document it automatically closes the window.

5 You will need to print this for the patient (Go to File-Print) and then save this to the patient record WARNING: When you save the document it automatically closes the window. You will have to reopen the plan in order to print it. If you are going to print the plan for the patient you need to do this first. You will then see this screen: Click OK. You have now finished your LTC review for the first condition. Ardens Care Plans Page 5 of 14 June 2017 v1

6 Once you have done the first LTC, the review template for second condition that the patient has appears: As above, click on start or skip to next. Once you have done all the conditions you will be taken back to this screen: You have now done the first part of the LTC review and care planning with the patient. You should have printed and saved the supplement / self-management documents for each condition. If you have missed any, don t worry you can still access them from this template. Ardens Care Plans Page 6 of 14 June 2017 v1

7 Find the specific condition you have missed on the list here. Right click and a pop up appears. Click on Action This will open the template and for that particular condition and you can get to the care plan at the bottom of the template. You do not need to re-complete the template. Query? Do I have to do all the reviews at the same time? Answer: No. Under the conditions section, each LTC tells you when the patient last had a review for that particular condition. Ardens Care Plans Page 7 of 14 June 2017 v1

8 You may not wish to redo the review, but you will need to open the template to print and save the disease supplement for this condition. If you have all the reviews completed and supplements printed, you can move onto step 2 The Core Care Plan. Step 2 Create the core care plan Click on Future Care Planning You will then see this screen: NB: If you need to print any specific care plans, you can do this by clicking here. Ardens Care Plans Page 8 of 14 June 2017 v1

If this is the case, tell the patient that these fields will appear on their care plan, but they don t have to make any decisions now. These fields can be filled in at a later date.

9 This is where you can discuss with the patient and record what they may like to happen if their condition gets worse. NB: Depending on the patient and their condition, you may feel that this particular appointment is not the best time to have the conversation. If this is the case, tell the patient that these fields will appear on their care plan, but they don t have to make any decisions now. These fields can be filled in at a later date. However, remember to explain to the patient the benefits of having this information recorded e.g. losing capacity in the future. On this page you will see a field called Patient Goals. Clicking on this box will open a new template. This is where you can record any goals you agree with the patient to help them to manage their condition(s). Ardens Care Plans Page 9 of 14 June 2017 v1

These goals will auto-populate into the core care plan.

Click on Print Generic Care Plan The New Letter form will open: Check the patient details and click on

This will now open a word document: You will need to print this for the patient (Go to File-Print) and

10 These goals will auto-populate into the core care plan. You now need to create the core care plan and can do that on this page. Click on Print Generic Care Plan The New Letter form will open: Check the patient details and click on Write Now. This will now open a word document: You will need to print this for the patient (Go to File-Print) and then save this to the patient record WARNING: When you save the document it automatically closes the window. You will have to reopen the plan in order to print it. If you are going to print the plan for the patient you need to do this first. Ardens Care Plans Page 10 of 14 June 2017 v1

Step 3 Medication Review As part of the care planning conversations and review of the patients LTCs, a medication review should take place. On the LTC template is a button called Medication.

11 You have now done the second part of the LTC review and care planning with the patient. Steps 1 and 2 combined provide the patients with a frailty score or with multiple LTCs, with a comprehensive care plan. Step 3 Medication Review As part of the care planning conversations and review of the patients LTCs, a medication review should take place. On the LTC template is a button called Medication. Click on this to start the medication review The following template will appear: This template will help you to complete the medication review for the patient. If you wish to do a more detailed review, you can click on the Full Drug Review button and this will open up a more detailed template. Step 4 Sharing the care plan Care plans are most effective when others involved in the patients care can view them. You will need consent from the patient to share their care record. If the patient consents to sharing you will need to record this within their record and enable record sharing. Ardens Care Plans Page 11 of 14 June 2017 v1

12 Click on Future Care Planning You will then see this screen: Click on Sharing Records A new template will open: Click on SystmOne Sharing In/Out Ardens Care Plans Page 12 of 14 June 2017 v1

13 This template will appear and you can record the patient s preferences. The patient s record can now be viewed by other organisations and you can see information recorded on SystmOne by other providers. More information on record sharing and the My Care Record Project can be found on the CCG website. Ardens Care Plans Page 13 of 14 June 2017 v1

14 Ardens Hints and Tips At the bottom of every template are the following buttons: Clicking on Ok will save the information you have entered into the clinical record and close the template. Ardens Care Plans Page 14 of 14 June 2017 v1

Frailty Care Planning Guidance for Ardens Users Templates to support care planning for frail patients

Frailty Care Planning Guidance for Ardens Users Templates to support care planning for frail patients Before you begin care planning with patients, you may find it easier to run your risk stratification