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Definition

dynamic, personalized plan including identified needed healthcare activities, health objectives and healthcare goals, relating to one or more specified health issues in a healthcare process

 

This is a concrete item and can be implemented directly

Term: care plan; 
Synonym: healthcare plan; 
Plural: care plans; 
Deprecated term: programme of care; 

Notes

NOTE 1 A care plan may be recorded in one or more health records.

NOTE 2 A care plan could be subdivided from different perspectives by different constraints. One example is uniprofessional care plan, for example, a nursing care plan with the constraint of only one specific healthcare professional involved. Other examples of specific constraints for a care plan are: care plan to address one health issue, one health condition, one contact, one clinical process, healthcare activities to be performed by one healthcare provider, etc.

NOTE 3 care plans are reviewed repeatedly during a healthcare process, each review based on a new healthcare needs assessment.

NOTE 4 The healthcare activities in a care plan follow a life cycle. Examples of statuses of such a life cycle are: 'planned', 'performed', 'cancelled', etc.; all of these statuses are included in the care plan.

NOTE 5 In EN 13940-1:2007 programme of care was the preferred term for this concept.

Examples

EXAMPLE A care plan for retinopathy in diabetics by video-retinoscopy, which involves the GP and an ophthalmologist and implies specific mobile equipment (video-retinoscope) with a camera.

UML class diagram

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0..* 0..* is recorded in ► 0..* 0..* has part 0..* 1 changes statuses of healthcare activities in ► 0..* 1 is scheduled in ► 0..* has part ► 0..* 0..* is planned in ► 0..* 0..* ◄ complies with 1..* 0..* applies ► 0..* 0..* ◄ implements 0..* 0..* ◄ is based upon 0..* 1..* has part 0..* 0..* addresses ► 0..* 1..* is result of ► 0..* 1..* addresses ► 1..* 1..* targets ► 1..* 1..* targets ► healthcare appointment: appointment for a contact healthcare appointment healthcare activity management: healthcare activity element during which the status of healthcare activities in a care plan are changed healthcare activity management health record: data repository regarding the health and healthcare of a subject of care health record multi-professional care plan: care plan encompassing healthcare provider activities performed by healthcare professionals having different healthcare professional entitlements multi-professional care plan healthcare planning: element of healthcare activity management where a care plan is created or modified healthcare planning health thread: defined association between healthcare matters as determined by one or more healthcare actors health thread core care plan: reusable content and structure for a potential care plan for a specified set of circumstances core care plan healthcare process: set of interrelated or interacting healthcare activities which transforms inputs into outputs healthcare process care plan: dynamic, personalized plan including identified needed healthcare activities, health objectives and healthcare goals, relating to one or more specified health issues in a healthcare process care plan healthcare activity: activity intended directly or indirectly to improve or maintain a health state healthcare activity uniprofessional care plan: care plan limited to those healthcare provider activities performed by healthcare professionals having the same healthcare professional entitlement uniprofessional care plan healthcare activities bundle: set of healthcare activities healthcare activities bundle clinical guideline: set of systematically developed statements to assist the decisions made by healthcare actors about healthcare activities to be performed with regard to specified health issues clinical guideline health objective: desired ultimate achievement of a healthcare process addressing health needs health objective protocol: customized clinical guideline protocol healthcare goal: desired achievement of one or more healthcare activities, considered as an intermediate operational step to reach a specific health objective healthcare goal health issue: representation of an issue related to the health of a subject of care as identified by one or more healthcare actors health issue healthcare actor: organization or person participating in healthcare healthcare actor
care plan

Required associations

a number of care plans addresses one or more health issues
a number of care plans has part one or more healthcare activities
one or more healthcare actors applies a number of care plans
a number of care plans is result of one or more healthcare plannings
one or more care plans targets one or more healthcare goals
one or more care plans targets one or more health objectives

Optional associations

a number of care plans complies with a number of clinical guidelines
a number of care plans implements a number of protocols
a number of healthcare processes is planned in a number of care plans
a number of healthcare activity managements changes statuses of healthcare activities in exactly one care plan
a number of care plans has part a number of healthcare activities bundles
a number of care plans is recorded in a number of health records
a number of care plans has part a number of care plans
a number of care plans has part a number of care plans
a number of care plans is based upon a number of core care plans
a number of care plans addresses a number of health threads
a number of healthcare appointments is scheduled in up to one care plan

Generalisations

care plan


The representation of a model conforming to the international standard ISO 13940 available through this site is provided by Oughtibridge Ltd.  It is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.  This work is based on a UML model prepared by Torbjørn Nystadnes of the Norwegian Directorate of Health, a subordinate agency of the Norwegian Ministry of Health and Care Services.