New care plans = 70% Review of care plans = 30% Total number of patients Number with a care plan Number without a care plan 100 20 80 Example New care plans = 70% (of 80) = 56 care plans Review of care plans = 30% (of 20)= 6 care plans 2) Completing Care Plans 2.1 Which Care Plan? SystmOne - Ardens Users SystmOne - Non Ardens Users EMIS Web Use the relevant condition specific templates to capture key information. Use the LTC review template to help you identify which condition specific plans the patient needs. Click on future care planning on Generic Care Plan (This is the foundation document) - make sure you select the code from the drop down box Click on Specific Care plan - this will take you to the plans for specific conditions Signpost patients (where appropriate) to self-management support on the Health in Herts webpages For end of life patients: Ask for consent to add information to the summary care record. Use the EPaCCS leaflet Continue to use the same Personal Care Plan that you used for 17/18 and have used in previous years as part of the avoiding unplanned admissions DES. Ensure patients are correctly coded with a GSF stage / Frailty code, where appropriate. Signpost patients appropriate) to support on the Health in Herts webpages. For end of life patients: Ask for consent to add information to the summary care record. Use the EPaCCS leaflet to explain how this works Continue to use the same Personal Care Plan that you used for 17/18 and have used in previous years as part of the avoiding unplanned admissions DES. Ensure patients are correctly with a GSF stage / Frailty code, where appropriate. Signpost patients (where appropriate) to support on the Health in Herts webpages. For end of life patients: Ask for consent to add information to the summary care record. Use the EPaCCS leaflet management management
Refer to the HPFT share care protocol for physical health checks for people with SMI – Read codes SystmOne (CTV3 Code) EMIS & Vision (v2 Code) SNOMED Concept ID Code (SNOMED replaces Read CTV3 & v2 in all GP systems during 2018) Mental health annual physical examination done XaJON 9H9 408404002 Goals and action plan Goal identification 67L 225294001 Review of Patient Goals XaXfH 8CMX 775501000000108 Care Plan documentation SystmOne - Ardens SystmOne - Non Ardens Users EMIS Web Use the relevant condition specific templates to capture key information. Use the LTC review template to help you identify which condition specific plans the patient needs. Click on future care planning Click on Patient Goals and set goals relating to physical health with patient Signpost patients appropriate) to support on the Health in Herts webpages Continue to use the same Personal Care Plan that you used for 17/18 and have used in previous years as part of the avoiding unplanned admissions DES to set patient goals. Signpost patients (where appropriate) to support on the Health in Herts webpages. Continue to use the same Personal Care Plan that you used for 17/18 and have used in previous years as part of the avoiding unplanned admissions DES to set patient goals. Signpost patients (where appropriate) to support on the Health in Herts webpages. management management