This section captures information relevant to their medical/health (both past and present), mental health, falls and mobility issues. It is good practice to include the approximate or exact date of diagnosis where known. It is also good practice to provide some information regarding some of the relevant side effects of a known condition.
For example, John experiences short-term memory issues, due to his dementia, where he cannot remember appointments. John gets frustrated so he likes to keep a diary where he records all upcoming appointments. Care professionals should regularly remind John to look at his diary.
Present medical (health) condition (ask for any symptoms to look out for, how do they affect the person, approximate or exact dates for diagnoses, if known)
Clinical Presentation:
Past medical (health) history (ask for any symptoms to look out for, how do they affect the person, approximate or exact dates for diagnoses, if known)
Clinical Presentation:
Medication Record (list all medication that the individual is currently taking, inc. dosage, frequency, and timings, as well as the storage of the medication; highlight any PRN medication and the times they need to be offered; specify any time sensitive medication; ensure that MAR charts are developed in line with the individual’s prescriptions; add, if needed, current prescription GP list, discharge letter, covert medication and the authorised paperwork should be available and this should also be reflected on the label and MAR)
Does the client need support with medication? Please specify the below:
Yes – (State prompt, assist, administer) / No / Self -medicated / Family given
Specific care needs for diagnosed health conditions (this section would identify the main health issues that the individual experiences such as diabetes, Parkinson’s, dementia, pacemaker etc. It would require a description about what the specific condition is that the individual has, and how this would affect the individual, and what the care professionals should look out for (signs and symptoms etc).
Mental Health (What mental health condition/concern does the individual face at the present/ faced in the past? How has this this/does this effect the individual? What support is in place or in needed to be put in place? What their mental health effect there physical health such as frailty?
Wellbeing E.g. stable mood / change in mood/ disengagement from interactions, Change in Individual’s circumstances e.g. bereavement, anniversary of deaths, loss of contact with important others, or received news that distresses them and may trigger them (including things watched on TV) – Link to Positive Behaviour support plan where required
End Of Life Documentation – Advance Care Plan, TEP, Respect, Peace, DNACPR (this form should be filled out by the healthcare professional and the individual). For more information on different document click here
Mobility (What are the concerns/ issues with mobility? What equipment does the individual use? How does this affect them? What support do they need with their mobility)
Ensure you include how somebody can practice mobility with staff, how far can they mobilise? Does improving mobility align with their goals? Are goals set to support the individual to improve mobility. Ensure that rather than the individual maintaining mobility, there are actions documented on how to improve mobility if applicable. Add photographs of specific equipment the individual uses (with permission) including explanation as to how to use the equipment safely. E.g. Slings.
Falls – (History of falls/ What are the frequency and characteristic sand context of the falls?)
- What was the reason for the fall – relate this to the risks identified in the multifactorial falls risk assessment, including their physical, cognitive, psychological and social resources.
- What are this individual’s patterns and trends of falls?
- What impact has the fall affected this individual’s physical and mental health?
- What is the severity of the falls?
The risks identified in the risk assessment should be carried over to the care plan so suitable interventions can be documented. Please ensure that this also triangulates to other parts of the care plan including mobility, nutrition, continence, functional ability, wellbeing, referrals from other professionals, diagnosed health conditions and medication if relates to an individual’s falls risk.
Find resources and templates here.
To include the persons goals, values, beliefs, and priorities.
Click here to use the World Falls guidance to support with recommended assessments and interventions.
Ongoing Support by Other Professionals
Use this section to record any support from other healthcare professionals. Please record the input, outcome, timeline and impact in care delivery:
GP / Dentist / Occupational Therapist / Physiotherapist / Social Worker / District Nurse / SALT team / Dietitian / Pharmacist – Community or PCN / Palliative Care Team / Other. All outcomes must support the ethos of Connected Lives
My Health and Wellbeing Care and Support Plan
Please use the information above to create a detailed plan that details how the individual is to be supported and assisted with their health and wellbeing.
My Desired Outcomes for My Health and Wellbeing
In this section, please highlight the desired goals in relation to their personal health and wellbeing. E.g., ‘I would like to manage my pain and be supported to attend my GP appointments’. Please detail how this goal will be met and what/who needs to be involved. All outcomes must support the ethos of Connected Lives.