Nurses and Aboriginal Health Workers (AHWs) working in primary health care assist GPs to manage their patient’s chronic conditions every day.  The patient will usually see the nurse first to compile the information into a plan which is then reviewed by the doctor.  Rarely does the GP alter the information in this plan, so what is presented to the patient and GP is important to the long-term care and management for the patient.  If the plan is too long it tends to remain unread by anyone including the patient. The goal is to make a plan that is user friendly to clinical staff and the patient/carer.

Clinical software makes it a lot easier with pre-made templates, but the plan still needs to be individualised to the patient.  The approach and management for each patient shouldn’t be generalised.

The first meeting with your patient should be about establishing trust and engaging the patient in their care. This can be a difficult task when you are staring at your computer trying to get everything into the plan.  The patient tends to get bored and not see the benefits of making the plan to begin with.

  1. Get to know your patient

The information in the plan needs to be relevant and up to date.  Take the time to review the patient file before you call them in.  This five or ten minutes will give you an overview of current conditions, last bloods, allied health and specialist correspondence and will let you identify gaps that will need to be addressed.  Use your progress notes shortcut and start filling in what you know.  This will give you more time with your patient face to face and find the missing pieces to develop a concise but comprehensive plan.

  1. Don’t forget the patient history

Most nurses skip the most important part of a care plan.  Updating the patient history.  You will all have seen a patient history added to the clinical software that contains multiple diagnoses with the same date.  The patient history attaches to every document that is sent from the practice including referrals, and other health care professionals involved in the patient care should receive a copy of the care plan.  Most referrals are triaged at the other end and if you don’t have all the relevant information your patient may be triaged as a lower priority when they shouldn’t be.  Patients are very good at knowing their history because they were there.  I usually start with the list of medications and ask them what they take the medication for and for how long.  You don’t need an exact date, the year in these events will let you put together an accurate timeline of events.  Also, you don’t know who entered the information before you, so you need to get this right.  Don’t forget to use coded diagnoses for the medical and surgical history when you are entering them.

  1. Patient details

The other important component of a care plan is the patient’s details.  Regardless of which clinical software you use, patient details usually include: demographic data such as ethnicity, allergies, smoking, alcohol, family and social history.  This needs to be reviewed every time, as these things can change, and the information is usually attached to every document leaving the practice.  A patient’s family and social history also allows the opportunity for your patient to open up and gives you a fuller picture.  It will also flag some management issues for their chronic condition.  Are they recently widowed or a full-time carer for a loved one?  Do they live alone?  Do they have support?  All these things can affect how they are managing their condition day to day.  A patient’s family history will also give clinical staff a better insight to early detection and prevention that they would otherwise have missed.

Time is the reason I hear frequently for not updating this information and engaging with patients, but time and practice is what it takes to find out the information you need in that first appointment.  I am usually asking questions and getting to know my patient as I’m doing other things like recording their observations.  I try to limit the time staring at the computer and focus my attention on the patient.  If you don’t engage the patient in that first care plan appointment you will most likely not see them for a review 3-6 months later.

  1. Short-term goals and regular reviews

Patients can sometimes be overloaded with information, especially those recently diagnosed with a condition so try not to add a long list of things they need to do.  I’ve found that patients with long term conditions need smaller short-term goals with regular reviews.  Giving the patient one or two tasks to complete before the next review makes it manageable for them.  When you see them next time and they’ve completed these two tasks they are more open for the next steps in management.  Some patients need some help to complete the tasks and you can help them do this in an appointment.  For example, a patient with diabetes may be due an eye exam.  I have found great benefit in helping patients take the first step in their management.  This is as simple as making a phone call to the local optometrist during their care plan appointment.  It breaks down the barrier of them making the first call or putting it off to another day.  I introduce myself on the phone and explain I have a patient that needs to make an appointment and then I pass the phone to the patient.  The patient gives their details over the phone, they select the date and time that suits them and just like that they have taken their first step.  Success!  While they are talking on the phone, I keep entering my progress notes.  I also find this useful when booking other appointments such as mammograms, podiatrist or other allied health appointments.  I usually make a note of the appointment, so when I see them for the review I can follow up to see the report or ask the patient if they attended and the outcome.