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Care Plans, Patient Passports and Portability

What is a Care Plan/Patient Passport?

Everyone with a long-term condition can have a care plan if they want one.

A care plan is an agreement between you and your health professional (or social services) to help you manage your health day to day. It can be a written document or something recorded in your patient notes.

Everyone who has a long-term condition can take part in making their care plan. It helps to assess what care you need and how it will be provided.

Also, try to talk about anything that might be worrying you. For example, some people want to talk about how lonely or anxious they feel, including their fear of hospitals!

By talking about your care plan with your GP, nurse or social worker, you can say how you want to manage your health and choose what's best for you. The care plan will be based on what you want so you're in control.

Patient Passports are a similar type of document produced by a number of NHS Trusts throughout the UK.  They have been primarily designed by Learning Disability departments within the Trust to help those who are not necessarily able to communicate their medical condition and treatment to medical personnel.  However the content of both documents can be very similar.

Why are these documents important?

Care planning is an essential part of healthcare, but is often misunderstood or regarded as a waste of time. Without such a document , important issues are likely to be neglected. Care planning provides a "road map" of sorts, to guide all who are involved with a patient's care. For those with long-term medical conditions then this document can highlight many issues that would not ordinarily find their way on to a patient's records held by their GP.

So for someone who uses oxygen and is in a wheel chair, the care plan may contain details about how oxygen tanks can be changed or the type of cylinder needed.  Not necessarily vital for emergency care but useful information nevertheless when contacting health services and asking for the right replacement equipment.

Other information that might be recorded are matters referring to the patient's likes and dislikes.  In one case a patient had a terrible fear of being admitted to hospital and her care plan stipulated that only in the most extreme of circumstances was a admission was to be allowed.

A healthcare professional needs to be able to match the available care provision against the clinical needs of the patient and this document acts as a bridge between the two.

The system of care plans is not working

Care plans, when prepared with time and care, can be a vital document.  There is one small problem though.  A nurse or doctor will sit down with the patient and prepare the care plan.  In some cases this can be just a paragraph and in others extend to a 25 page mini novel.  Once prepared the healthcare professional will often give a hard copy of the document to the patient and the electronic version will stay on their computer.  And this is where the problems start.

Care plans are just not portable.

A patient with a complex medical condition and with a carefully prepared care plan is going to become unstuck if they are admitted to a hospital or other facility that does not have access to that plan.  Even knowledge of the patient's NHS number will not always help.  All the patient can do is carry with them the printed care plan just in case a medical professional needs to see it in an emergency.

Where does tap2tag come in?

We have been working with East Kent University Hospital NHS Trust and Ether Creative to develop an effective method whereby a Patient Passport can be completed with the patient and specialist nurse.  Initially designed for their Learning Disability department the trial with around 20 patients and carers is due to start soon.

We have upgraded the medical profile on our own website to allow all users to upload up to four documents into their medical records.  This can include a patient passport/care plan but might also include a scanned image of a Do Not Resuscitate ("DNR") letter or specialist medical notes from the consultant.  You can even upload your maternity plan!  The choice will be up to the user.

In essence we have enabled care plans to become truly portable allowing patients to carry an electronic copy of their important documentation anywhere in the UK and throughout the world.

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