Care Plans

Use the Chronic Disease Management (CDM) feature to create a care plan for your patients.

Before you begin

Permissions:
  • View Care Plans
  • Update Care Plans
Existing care plan templates in CDM and General Practitioner Chronic Condition Management Plan (GPCCMP) templates are available in the Letter Writer. You can create the required care plan from the Letter Writer iconLetter Writer section. For more information about creating a care plan, see Write a Letter.
Example of selecting care plan (GPMP or GPCCMP)

About this task

Select the required template to create a care plan for your patient.
Note:
TCA and GPMP + TCA plans are superseded by GPCCMP.

Procedure

To add a care plan:
  1. From the PatientPatient Search or Patient Queue iconPatient Queue, select a patient and click Consult buttonConsult.
  2. In the Consult iconConsult panel, select down iconMore > CDMCDM.
  3. In the CDM section, select a care plan from the list of available Care Plan templates. For example, GPMP.
    Example care plan
    Tip:
    Previously created care plans are listed in the CDM list. Select an existing plan to review it or select a template to add a new plan.

    If you have the Create Care Plan on behalf of HCP permission and are creating the care plan on behalf of a health care professional, select their name from the HCP list and click OK.

  4. In the care plan, information from the patient's Authority Information, Medications, Conditions, Health Summary, Measurements and other sections are displayed on the left side. To update this information, click Update.
    In the Authority Information section:
    • If the patient wants an interpreter for their care plan, set Interpreter required.
    • To add carer details for the patient, set Requires a carer and update the details in the Carer's Details section.

    Example care plan
  5. To include or exclude information, set or clear Include on the corresponding row.
  6. To add a condition to the care plan:
    1. From the Conditions list, select a condition or start typing the condition name to search for it. For example, Asthma.
      Conditions selection example
    2. To edit a row of information, click it to activate edit mode and make the required changes.
      Condition in edit mode
      • Assign providers to the suggested needs. For example, we have indicated that the need of Give patient a better understanding of asthma in the Needs column, must be provided by an Asthma Educator, in the Assignee column.
      • To add more providers:
        1. Click the Assignee column.
        2. From the list, select the provider.
        3. To add multiple providers, repeat the process.
        Tip:
        To remove a provider, click remove iconRemove.
      • If a row of information does not relate to your patient, click Delete buttonDelete.
        Tip:
        This option is available only in edit mode.
      • To save the edited condition to the Favourites list, click Favourite Template iconFavourite at the top right of the Conditions list.
        Example favourite condition
    3. To save the changes, click anywhere outside the row.
    4. To add additional goals, needs or tasks for the selected condition, click Add needs/ goals/ task at the bottom of the condition.
    5. To add multiple conditions, repeat the process.
      Depending on the condition, you might be required to include additional providers in the care plan. This list is displayed at the bottom of the condition details. Enter an assignee for each speciality listed. The assignee is mandatory.
      Tip:
      The providers that displayed in the Additional Providers list are copied from the Assignee sections of your care plan. To remove a provider from this list, locate them in the care plan body and remove them.
    6. Depending on the condition, a recall is automatically added to the condition at six months in the future. To edit the Recall date, click the calendar and select a new date.
    7. To remove a condition from the care plan, click Remove next to the condition.
      Tip:
      When you are in edit mode, this action is not available.
  7. To save the care plan, select one of the following options:
    • Save as draft - saves a care plan as draft.
    • Save and Print - saves and prints the care plan. The saved care plan is displayed in the Print Preview window, from where you can print or download the file.
    Tip:
    To close the Care Plan panel without saving, click Cancel. After cancelling, you are redirected to the Consult iconConsult panel.

Results

The completed care plan is saved to the Actions section of the Consult iconConsult panel and is printed.
Example Actions
For the TCA and GPMP+TCA care plans, an EDC form is also added to the Actions section. This is a government requirement when certain specialities are selected.
Note:
TCA and GPMP + TCA plans are superseded by GPCCMP.

What to do next

When the consult ends, the plan is added to the Patient Timeline iconPatient Timeline. For more information, see Care Plans in the Timeline.