What are Care Plans?
Care Plans are a whole new way of documenting in Cortex. Rather than having a static note that can only be addended, a Care Plan is a repeatedly editable document designed to reflect a patients current state and plan of care.
Care Plans can be edited by any user involved in the patients care, however local business rules should be followed around the frequency of edits and content that should/can be changed.
At any time, a snapshot of the care plan can be placed in the patients timeline. These are treated as signed notes by Cortex.
Updating Care Plans
Update a Careplan when there has been a change that needs to be documented.
This can be done as frequently as required during a shift, it is important that the most current information is documented.
Snapshots
Snapshots are taken to file a copy of the current state of the Care Plan within the patient’s timeline feed.
Business rules will apply for each Care Plan type but as an example, a Nursing Care plan may be expected to be snapshotted at the end of shirt as a record of care, ideally just before handover.
Rescinding a Care Plan
Rescinding the Care Plan will rescind all previous snapshots related to this Care Plan eg: for a patient that has had an extensive length of stay and contains for example 100 Care plan snapshots they will all be rescinded.
RESCINDING SHOULD ONLY EVER BE DONE AFTER CAREFUL CONSIDERATION
The current state of the Care plan will also be rescinded and all information contained will be lost and have to be re-entered.
Typically a Care Plan would only be rescinded if it had been started on an incorrect patient and clinical information may have been viewed by other users.
Rescinding a Snapshot of the Care Plan will only rescind that one snapshot and should be completed if a snapshot contains any incorrect information. A summary of the incorrect information should be provided in the “reason for rescind” box.
Ending a care plan
This will place the final snapshot of the Care Plan into the patients timeline for the admission.
The Care Plan will no longer be available to be updated.
Typically a Care Plan would be ended as a patient is discharged.