Writing Good Care Plans

Transcription

1 Writing Gd Care Plans A gd practice guide Cre Care Standard Care Planning: Yu will have a clear care plan

2 1. Intrductin Cntents 2. Where and hw the care plan shuld be written 3. Cntent f care plans 4. Crisis and Cntingency Plans 5. Carers Supprt Plans 6. Writing gd care plans 7. Accessibility and Cmmunicatin 8. Respnsibilities f the Care C-rdinatr 9. Different types f care plan 10. References 11. Trust Minimum Standards fr Clinical and Practice Recrds Writing Gd Care Plans 1 Amended 2012

3 1 Intrductin Purpse This bklet is intended t supprt gd practice in Care Planning, thrugh a summary f current plicy, standards, guidance and recmmendatins, tgether with tips and suggestins abut hw t write a gd care plan which: Meets prfessinal, lcal and natinal standards; Clearly utlines aims, actins and respnsibilities; Supprts care planning under systems such as: the Care Prgramme Apprach, Health Actin Planning etc. Interacts effectively with ther care planning systems; and Is accessible t everyne wh is part f it. Care Plan A plan f care is smething that describes in an easy accessible way the services and supprt being prvided, and shuld be put tgether and agreed with the persn thrugh the prcess f care planning and review. Care Planning invlves: Gathering and sharing stries: the views f all cncerned, including the persns/child s, family/carers, and prfessinals views A systematic review f the areas f need Explring and discussing infrmatin: t help wrk ut what s mst imprtant Gal setting: what d we want t achieve? Actin planning: what are we ging t d, wh is respnsible, and when will it be reviewed? Risk Management: hw d we make care as safe as pssible? Writing Gd Care Plans 2 Amended 2012

4 A Care plan is: A recrd f needs, actins, and respnsibilities; A tl fr managing risk; A plan which can be used and understd by service users/patients, families and carers and ther agencies, as well as clleagues, in a crisis; Smething which peple feel they wn; Based n a thrugh assessment f need; A multi-prfessinal, multi-agency endeavur; C-rdinated by the mst apprpriate persn, such as a Care C-rdinatr; Prduced in the mst apprpriate frum; Shared effectively with thse wh are part f it; the written recrd f a plan f actin negtiated with the persn t meet their health and scial needs A Care Plan is nt: a bureaucratic exercise, but is an essential element in engaging service users and cmmunicating what the service can and will d, and what respnsibilities they, family and carers, and the persn cncerned, will have; r a wish list, but is a plan f agreed elements f care a waste f time, but a valuable aid t prviding care that everyne understands and has agreed t See fr mre infrmatin abut the standard Writing Gd Care Plans 3 Amended 2012

5 2 Standards Standards fr care planning cme frm a number f surces, 1. The Trust Cre Care Standard fr Care Planning is: Yu will have a clear care plan 2. The Care Quality Cmmissin Essential Standards f Quality and Safety, includes Outcme 4 The Care and Welfare f peple wh use services. This requires that : The assessment, planning and delivery f their care, treatment and supprt: Is centred n them as an individual and cnsiders all aspects f their individual circumstances, and their immediate and lnger-term needs. Is develped with them, and/r thse acting n their behalf. Reflects their needs, preferences and diversity. Identifies risks, and says hw these will be managed and reviewed. Ensure that plans f care, treatment and supprt are implemented, flexible, regularly reviewed fr their effectiveness, changed if fund t be ineffective and kept up t date in recgnitin f the changing needs f the persn using the service. See References fr specific prvisins 3. Legislatin and plicy including a. The NHS and Cmmunity Care Act 1990 b. The Children Act 1989 c. The Mental Health Act 1983 d. The Mental Capacity Act 2004 e. Varius Carers Acts Writing Gd Care Plans 4 Amended 2012

6 3 Where and hw the care plan shuld be written This may have a majr impact n hw effective the care plan is. A care plan that is written by ne persn alne in an ffice may include all the key elements, but is nt likely t be as effective in practice as ne which is written in partnership with the persn and thse wh are cntributing t the plan. A sense f wnership by all thse cncerned (and in particular the persn themselves) is vital in making the plan translate int reality, which can be prmted by: Using peple s wn wrds and phrases (familiar and cmfrtable language, which avids jargn and abbreviatins); Recgnising that care plans exist fr the benefit f the service user, and shuld be based arund the needs f that persn, nt arund the services available; Invlving the persn in agreeing and writing the care plan as much as pssible, including the pprtunity t sign the care plan; Prducing the plan in a frmat and style that the persn is cmfrtable with Being flexible in the apprach t the service users invlvement; Often, cncerns are expressed abut the time needed t write cmprehensive plans and, as a result, care plans can becme jargnised shrthand fr what services will d. This type f plan is unhelpful t service users, carers and staff. Set realistic time aside fr this imprtant Care Standard Writing Gd Care Plans 5 Amended 2012

7 3 Cntent f care plans Care plans fr all service users shuld include: Why are we ding this? (aims) What are we planning t achieve? (utcmes) Hw are we ging t d it? (actins) Wh will d it? (respnsibilities) Where will it be dne? (times, lcatins) When will it be dne by? (timescales) Any needs relating t REGARDS (race and culture, ecnmic disadvantage, gender, age, religin/spirituality, disability r sexuality) The care plan shuld als: Include the persns rle Fcus n peples strengths Reflect the individuals cultural and ethnic backgrund as well as their gender and sexuality Include actin and utcmes in all relevant aspects f an individual s life Include crisis and cntingency arrangements; Give the date f the next planned review (within a year). Reflect transfer details if apprpriate Identify unmet needs Writing Gd Care Plans 6 Amended 2012

8 4 Crisis and cntingency plans Crisis and cntingency plans must be based n the individual circumstances f the persn, hwever, where there are n risks identified, a cntact card may be sufficient. This must include 24 hur/7 day a week cntact details. Crisis plans shuld set ut the actin t be taken if the service user becmes very ill, r their health is deterirating rapidly. The plan must include: Wh the service user respnds best t and hw t cntact them; Previus strategies that have been successful in similar situatins; Early warning signs and relapse indicatrs; Cntingency plans shuld help t prevent a crisis develping when, at shrt ntice, the C-rdinatr is nt available r part f the care plan cannt be prvided. The plan must include: Infrmatin abut wh t cntact if the C-rdinatr is nt available; A cntingency fr any key elements f the care plan. Gd practice example: When Jay stps making eye cntact and starts pacing, make sure that he has a quiet place t g where ther peple will nt disturb him, cntact his Mum, and his GP. Writing Gd Care Plans 7 Amended 2012

9 In practice it may be useful t think abut: Which elements f the care plan are essential Thse elements withut which the persn s well-being r safety wuld be seriusly cmprmised Making sure that yu have the understanding and acceptance f their rle, f thse mentined in the plan Crisis plans fr peple with mre cmplex needs, such as thse wh need CPA, shuld be mre than just a list f telephne numbers Crisis plans will ften be referred t when the service user is experiencing distress, and events may be fast-mving They shuld reflect service users views and wishes It shuld be written with the service user and their carer(s) wherever pssible By being explicit and instructinal the plan is mre beneficial t bth the service user, their carer(s) and ther service staff 5 Carer s Supprt Plan All infrmal carers wh prvide regular and substantial supprt fr a service user are entitled t an assessment f their caring, physical and mental health needs, and a supprt plan t meet thse needs. Writing Gd Care Plans 8 Amended 2012

10 This may include (depending n the needs identified): Infrmatin, including where and hw t access services, bth during ffice hurs and in a crisis; Actin t meet defined cntingencies; What will be prvided t meet the carers identified mental and physical health needs; Actin needed t secure advice n incme, husing, educatinal and emplyment matters; Arrangements fr shrt term breaks/respite; Arrangements fr scial supprt, including access t carers supprt grups; Infrmatin abut appeals r cmplaints prcedures. The plan may (with everyne s agreement) be part f a jint ne with the service user. Where n needs are identified, r the carer refuses an assessment, a cntact card fr the carer may meet the requirements f the supprt plan (which shuld include wh t cntact ut f hurs. The supprt plan must be reviewed at least annually. Other agencies may be cmmissined t prvide the assessment and supprt plan. Fr mre infrmatin see the Cre Care Standards website Write a supprt plan fr a carer wh needs supprt with a leisure activity: Writing Gd Care Plans 9 Amended 2012

11 6 Writing Gd Care Plans Think lgically and bjectively abut what is being written. We ften use statements such as mnitr mental health r mnitr medicatin with n indicatin abut what precise aspects f smene s mental health shuld be mnitred, r hw these shuld be mnitred Remember: Service users can write their wn care plans if they s wish Service users receive a cpy f their care plan and have an pprtunity t sign t say that they agree with the plan. If service users dn t want t be invlved, make a nte f this, and ask them again later Care plans reflect the needs f the individual In practice, it may be useful t write the care plan as I need, t encurage the service user t think abut what he/she needs Statements f actin that are instructinal and able t be fllwed in yur absence. Interventins that relate directly t the needs and gals T make text mre inviting t read, use: Shrt sentences in general n mre than wrds lng Present and active tenses, where pssible, fr example, yur appintment is n nt yur appintment has been made fr Writing Gd Care Plans 10 Amended 2012

12 Bulleted r numbered pints t divide up cmplicated infrmatin Small blcks f text. D nt use lng paragraphs divide them up using headings and new paragraphs White space makes the infrmatin easier t read Large bld fnt emphasizes text. Avid UPPER CASE letters, italics, and underlining as they make the text mre difficult t read. WRITING IN CAPITALS READS AS IF YOU RE SHOUTING. Numbers frm ne t nine are easier t read if they are in wrds, and numbers frm 10 can be represented as numbers The fnt size shuld be between 12 pint (minimum) and 14 pint. Hwever, if yu are prviding infrmatin fr elderly peple, r thse with sight difficulties, yu shuld always use at least 14 pint. Typed infrmatin shuld usually be in Ariel fnt Identifying needs: Care plans shuld always identify needs (rather than services) i.e. Instead f: Need = Hme help It shuld read: Need = Have a fire lit and help with mrning rutines Accuracy and cmpleteness: The care plan shuld always be able t be picked up and used by clleagues if the Care C-rdinatr r lead prfessinal is nt there, s must include enugh infrmatin fr smene else t implement the plan i.e. rather than: Need Actin Respnsible Hme help every day DSO The Actin t meet the need might be t have a hme help, r supprt fr the persn t learn t d this, r t cnsider a change Writing Gd Care Plans 11 Amended 2012

13 f heat surce, depending n what the persn feels wuld best supprt their independence. Gd practice example: Need Supprt t enable Jhn t live independently Actin 1. Supprt wrker t visit Jhn each day at agreed times and places fr 1 hur Mnday Friday t: Remind him f appintments and medicatin Prvide a chance fr Jhn t develp skills in self-care by wrking with him n things like firelighting 2. Supprt wrker t attend reviews with Jhn 3. Review in 3 mnths time Respnsible Stella Jnes (Supprt wrker Recvery team 3) Jhn Smith (service user) Try writing a better care plan Instead f: Need Actin Respnsible Day Hspital A better care plan wuld be: Reminiscence Every Thursday Manager Need Actin Respnsible Writing Gd Care Plans 12 Amended 2012

14 Service User-Centred plans It can be very effective t write care plans in a service usercentred way, as if in the persns wn vice. The example belw shws the difference in apprach Interventin Mnitr side-effects f medicatin Service user-centred interventin 1. I will tell my Gill my Care C-rdinatr if I have any side-effects frm the medicatin, such as vmiting, shaking, headaches, nausea, r stiffness in my jints. When I see Gill, she will ask me abut this. 2. Gill will write dwn any side-effects in my ntes and talk t the dctr abut them with me. 3. Gill and I will fill in a rating scale t help manage any side-effects Cmplex Care Plans Care Plans ften include ther agencies, but there are sme situatins in which it is particularly imprtant t have clear infrmatin, and t explain in mre detail what all the respnsibilities are, particularly where the persn: Has a learning disability Has substance misuse prblems Misuses alchl Has safeguarding issues Is a vulnerable adult Has cgnitive prblems Is a child Writing Gd Care Plans 13 Amended 2012

15 7 Accessibility and Cmmunicatin Until a care plan has been effectively cmmunicated t the peple wh need t see it, it remains nly a plan. A care plan fund nly in the file will nt wrk very well. Hwever, simply sending ut a written cpy in English n paper may nt be enugh, and sme f the recipients may nt be able t access this. Issues t cnsider include: Level f literacy f the reader/s Use f languages ther than English Sensry impairments and disabilities Cgnitive impairment Age It is als essential that the care plan is legible, and typed/printed plans are t be preferred wherever pssible. When writing infrmatin fr service users, remember the fllwing pints: Use everyday language. Avid jargn and acrnyms, and use plain language t make it easier t read. As many as seven millin peple (abut ne in five adults) in England have prblems with basic literacy and numeracy, but that des nt mean that yu shuld be patrnising r r use childish language (Lrd Mser A Fresh Start 1999) Use service user-friendly text. Use persnal prnuns such as we and yu. D nt use frightening language. It is difficult t avid using sme medical terminlgy, but give an explanatin Avid instructins. Fr example, d nt just say dn t eat anything fr 12 hurs befre an peratin explain why Writing Gd Care Plans 14 Amended 2012

16 Be up t date. Give the mst recent practice and latest phne numbers Let peple knw if the infrmatin is available in ther frmats, fr example a CD r tape Cnsider the need t use: Manual/sign languages such as British Sign Language, Makatn, Braille etc. Simplified language Larger size type Symbls r pictures Audi tapes, Vide tapes/dvd s Translatin int languages ther than English S the care plan must be sent t everyne wh plays a part in it, and made available t peple wh d nt regularly play a part in it but may need access in a crisis, by making sure it is held in an accessible IT system, as well as in files. 8 Respnsibilities f the C-rdinatr The C-rdinatr is respnsible fr making sure that the care plan is: Prduced; Includes a crisis and cntingency plan; C-rdinated; Circulated; Reviewed Hwever, smene else may carry ut these functins, as lng as the C-rdinatr c-rdinates them. Writing Gd Care Plans 15 Amended 2012

17 In practice it wuld be useful t ask: What the service user wuld like frm mental health services What he/she wuld like t achieve Hw they feel this culd be achieved Hw they feel they culd cntribute Abut wh the service user feels cmfrtable fr yu t talk with, and gain permissin fr this In practice it wuld be useful t think abut: Imagine: the care plan being read by smene ther than yurself actins being SMART (specific, realistic and achievable (with resurces available) the care plan being a useful cmmunicatin tl in times f relapse r crisis what level f detail is needed in the plan t achieve the gals what supprt is needed and in what circumstances If yu were nt at wrk wuld anther wrker be able t identify what t d? Trying t wrk ut if there is a plan fr what t d in an emergency if it s nt in the care plan? Trying t fllw anther wrker s care plan that is t brad t be f use t the service user and ther staff Writing Gd Care Plans 16 Amended 2012

18 9 Different types f care plan There are a number f different planning prcesses that may impact n peple using health services. The guidance prvided in this bklet is apprpriate fr the majrity f these. Where different r expanded standards apply, these have been listed. A brief summary f the main types is prvided belw: Mental Health Care Plan (if CPA is nt needed) A plan prduced as the result f a mental health assessment f need A written plan which may be either prduced n a care plan frm/frmat r as part f a letter which is identified as being a care plan C-rdinated by a lead prfessinal Reviewed at least every year Mental Health Care Plan (CPA is needed) A plan prduced as the result f a mental health assessment f need A written plan which may be either prduced n a care plan frm/frmat r as part f a letter which is identified as being a care plan C-rdinated by a Care C-rdinatr Reviewed at least every year, with the date f the next review set at this ne Carers Supprt Plan A plan prduced as the result f an assessment f a carer s mental and physical health needs, caring, leisure and emplyment needs Writing Gd Care Plans 17 Amended 2012

19 It will always be written, but may be in the frm f a cntact card, a separate written plan, r as part f a jint plan with the service user May be c-rdinated by the (Care C-rdinatr r lead prfessinal, but where the assessment and majrity f the service is prvided by mainstream scial services, crdinatin may be dne there, r by a service cmmissined t prvide the service Reviewed at least annually Sectin 117 aftercare plan A plan prduced fr smene with an entitlement t aftercare under s.117 f the Mental Health Act 1983 (wh has been n a s.3, 37, 47, 48). Services prvided under the plan cannt be charged fr by health r scial services (e.g. residential care) A written plan, which must be signed n behalf f health and scial services. It must be prduced befre the persn is discharged frm hspital, preferably at the s.117 pre-discharge meeting (see Mental Health Act 1983 Cde f Practice fr guidance). C-rdinated by a (CPA) Care C-rdinatr Reviewed at least every year as part f the regular CPA review. Entitlement under s.117 must be signed ff by bth health and scial services when the persn n lnger needs mental health aftercare, within 3 mnths f the discharge. Direct Payments Plan Direct Payments are cash payments made in lieu f sme services t individuals wh have been assessed as needing cmmunity care services t meet scial needs. They can be made t disabled peple aged ver 16, parents f disabled children, r carers aged ver 16. A plan prduced t prvide cmmunity care, which shuld include: Writing Gd Care Plans 18 Amended 2012

20 Needs identified which relate t direct payments Hw the services will be secured, what supprt will the service user need, and hw it will be prvided Emergency cver arrangements Csts and any cntributins Mnitring and review arrangements Cnditins and arrangements fr discntinuance A written plan, which shuld be cpied t the service user. The plan may include sme services prvided directly and sme thrugh direct payments. It may be part f the verall care plan C-rdinated by the Care C-rdinatr r scial services wrker Reviewed regularly Wellness Recvery Actin Plan (WRAP) WRAP is a self-help system develped by peple with persnal experience f mental health prblems, struggling t cpe and develp a healthier lifestyle. It is a systematic apprach t selfmanaging yur life and prmting self-grwth, self-esteem and develping cping strategies that wrk fr yu. WRAP is a written plan that mves and changes with yu becming yur persnal plan t help yu cpe with life and everything it thrws yur way. WRAP will help yu mnitr yur life and help yu stay well and in charge f yur life even when yu becme unwell r when life changes cause yu prblems yu didn t fresee. A plan written by the persn themselves and cvering: Daily maintenance plan (feeling well, daily list, dreams and gals reminder list) Wellness tls (strategies t prmte well-being) Symptm mnitring Triggers and early warning signs Writing Gd Care Plans 19 Amended 2012

21 Crisis plan (feeling well, symptms, supprters, health care and treatments) Pst crisis plan (recgnising recvery) It may cver all the issues required under CPA, r a supplementary/jint care plan may be needed. This shuld be discussed between the service user and Care C-rdinatr A written plan, shared at the persn s chice C-rdinated by the persn themselves Reviewed whenever the persn wishes Health Actin Plan (LD) An actin plan ffered t peple with learning disabilities t describe the services being prvided t supprt them. Fr peple with mental health prblems and learning disabilities, this equates with the CPA care plan A written plan which frms part f the persn-centred plan Prduced in partnership with the persn primary care and GP s Reviewed at the fllwing stages f the persn s life: Transitin frm secndary educatin with a prcess fr n-ging referral; Leaving hme t mve int a residential service Mving hme frm ne prvider t anther Mving t an ut f area placement Changes in health status, fr example as a result f a perid f in-patient treatment On retirement Whe planning transitin fr thse living with lder family carers Writing Gd Care Plans 20 Amended 2012

22 Lng Term Cnditins Care Plans Lng term cnditins care plans are used fr adults and children living with lng term cnditins such as diabetes r COPD. They are used in Primary Care, and include the stages f: Preparing, Planning, and Maintaining. The care plan is simply a recrd f the utcmes f the care planning discussin between an individual and their healthcare prfessinal. A persnalised care plan shuld include ther infrmatin such as agreed gals, persnal preferences, aspiratins and gals, and cntingency plans in additin t treatment plans. The plan is wned by the individual. The plan is c-rdinated by the health prfessinal and the individual The plan is usually reviewed annually by the individual and the health staff in partnership Lked after children Care Plans The lcal authrity has a primary duty set ut in sectin 22(3) f the 1989 Children Act t safeguard and prmte the welfare f the lked after child and t act as gd crprate parents t enable each lked after child t achieve his/her full ptential in life. Care planning and case reviews are abut bringing tgether children wh are lked after, their families, the child s carers and prfessinals, in rder t plan fr the care f the child and t review that plan n a regular basis. The child s care plan prvides the verarching vehicle fr bringing tgether infrmatin frm the assessment acrss the seven dimensins f the child s develpmental needs [regulatin5] and frm any ther assessments f the child and his/her family. The health and educatin dimensins f the care plan are ppulated by the health plan [regulatin7] and the persnal educatin plan (PEP) [regulatin5(b)(ii)]. Using the dimensins relating t a child s develpmental needs, parenting capacity and wider family and envirnmental factrs, the care plan shuld be based n the infrmatin ascertained Writing Gd Care Plans 21 Amended 2012

23 frm the assessment and draw n knwledge abut interventins that are likely t be mst effective fr the needs t be addressed.. Persn Centred Plan (PCP) A plan which starts with the wishes and aspiratins f the individual with learning disabilities, and which shuld help the persn exercise chice abut husing, educatin, emplyment, supprt and leisure A written/pictrial plan C-rdinated by the persn themselves Reviewed whenever they wish Prisners Release plans Where a persn nw in prisn was previusly cared fr by mental health services, and they have been supprted thrugh CPA in prisn, the care plan shuld (with the prisner s cnsent) be frmulated with the full invlvement f their Care C-rdinatr befre release. Its aim is t prvide n-ging integrated and effective aftercare fr prisners with mental health, substance misuse, r c-mrbidity prblems. T prvide a flexible aftercare service which is respnsive t the cmplex aftercare needs f high-risk ex-prisners and t prvide seamless cntinuity f care fr ex-prisners n CPA A written plan, cpied t the prisner C-rdinated by the Prisn Healthcare service wrking with the (CPA) Care C-rdinatr Reviewed at least every six mnths, including plice, prbatin and husing clleagues where relevant. Writing Gd Care Plans 22 Amended 2012

24 10 References Essential Standards f Quality and Safety Care Quality Cmmissin Outcme 4 - Care and Welfare f peple wh use services Care and welfare f service users Regulatin 9. (1) The registered persn must take prper steps t ensure that:each service user is prtected against the risks f receiving care r treatment that is inapprpriate r unsafe, by means f (a) the carrying ut f an assessment f the needs f the service user; and (b) the planning and delivery f care and, where apprpriate, treatment in such a way as t (i) meet the service user s individual needs, (ii) ensure the welfare and safety f the service user, (iii) reflect, where apprpriate, published research evidence and guidance issued by the apprpriate prfessinal and expert bdies as t gd practice in relatin t such care and treatment, and (iv) avid unlawful discriminatin including, where applicable, by prviding fr the making f reasnable adjustments in service prvisin t meet the service user s individual needs. Regulatin 9 f the Health and Scial Care Act 2008 (Regulated Activities) Regulatins 2010 Prmpt: Peple wh use services have safe and apprpriate care, treatment and supprt because their individual needs are established frm when they are referred r begin t use the service. The assessment, planning and delivery f their care, treatment and supprt: Is centred n them as an individual and cnsiders all aspects f their individual circumstances, and their immediate and lnger-term needs. Is develped with them, and/r thse acting n their behalf. Reflects their needs, preferences and diversity. Writing Gd Care Plans 23 Amended 2012

25 Identifies risks, and says hw these will be managed and reviewed. Ensures that risk assessments balance safety and effectiveness with the right f the persn wh uses the service t make chices, taking accunt f their capacity t make thse chices and their right t take infrmed risks. Ensures that plans f care, treatment and supprt are implemented, flexible, regularly reviewed fr their effectiveness, changed if fund t be ineffective and kept up t date in recgnitin f the changing needs f the persn using the service. Maintains their welfare and prmtes their wellbeing by taking accunt f all their needs, including: physical mental scial persnal relatinships emtinal daytime activity Ensures cntinuity in their care, treatment and supprt as a result f effective cmmunicatin between all f thse wh prvide it, including ther prviders. Enables peple t maintain, return t, r manage changes t their health r scial circumstances. Is undertaken t reduce the risk f deteriratin in their health status. Encurages the preventin and early detectin f ill health, including relapse, wherever there are real factrs that present a risk t their health and welfare. Enables them t make healthy living chices cncerning exercise, diet and lifestyle. Children wh use services are: Fully infrmed f their care, treatment and supprt. Able t take part in decisin making t the fullest extent that is pssible. Asked if they agree fr their parents r guardians t be invlved in decisins they need t make. Writing Gd Care Plans 24 Amended 2012

26 Able t benefit frm an envirnment that is apprpriate t their age and individual needs. Peple wh use services have their needs met thrugh the care prgramme apprach: If they meet the criteria set ut in Refcusing the Care Prgramme Apprach: plicy and psitive practice guidance Peple with a learning disability wh use services: Are supprted t have a health actin plan develped by their primary care trust. Peple using rehabilitatin r treatment services fr substance misuse have: Their care, treatment and supprt ptins explained befre they start t use the service. These include any restrictins identified, and the alternatives, risks and benefits. Writing Gd Care Plans 25 Amended 2012

27 11 Trust Recrding standards Standard 1 - Health recrds (hwever recrded) cntributing t the care f the service user t be accessible t Health staff invlved in the care f the service user Standard 2 - Health recrds (hwever recrded) cntributing t the care f the /persn t be accessible t them as apprpriate t their circumstances Standard 3 - Health recrds t cntain a cmplete set f identificatin data Standard 4 - Health recrds t be cntempraneus, upt-date and chrnlgical Standard 5 - Health recrds t be legible Standard 6 - All entries in Health recrds t be dated, timed, and signed Standard 7 - Health recrds t be maintained in a way that enhances accuracy Standard 8 - Alerts, including allergies and reactins t be cmpleted within the Health recrd Standard 9 - The Health recrd t (a) cntain all relevant clinical infrmatin, (b) be f high quality, and (c) be cmplete Standard 10 - The Health recrd must cntain infrmatin abut children wh are in regular cntact with patients/service users, clearly identifying any safeguarding cncerns. The child health recrd must cntain any safeguarding cncerns. Standard 11 - The Health recrd t include clear evidence f all patient/service user and carer invlvement Standard 12 - The Health recrd t cntain discharge/transfer/leave infrmatin Writing Gd Care Plans 26 Amended 2012