Assessment & Care Planning Definitions
Assessment can be defined as
“A process of gathering and discussing information with the patient and/or carer/supporter in order to develop an understanding of what the person living with and beyond cancer knows, understands and needs. This holistic assessment is focused on the whole person, their entire well-being is discussed – physical, emotional, spiritual, mental, social, and environmental. The process culminates when the assessment results are used to inform a care plan.”
The care plan can be defined as
“A plan, based on the diagnosis and holistic assessment of the patient. The essential components will include identification of issues related to the diagnosis. It will need to prioritize the patient’s issues and include a statement on the specific actions and approaches to address them – and recognize issues which are not be readily capable of resolution. The assessment and care plan process should ensure that care is consistent with the patient’s needs and progress toward supported self management.”
The Treatment Summary
The Treatment Summary for cancer is about one episode of cancer treatment and care, completed at the end of a cancer treatment cycle. It is shared with the patient and their GP. The Treatment Summary describes the treatment that that person has received, the side effects and signs and symptoms of recurrence, and will inform the Summary Care Record and GP Cancer Care Review.
The Summary Care Record
The Summary Care Record is the record of all the care that a person has received, so may include eg diabetes, flu and / or cancer on it. It is not a single document. The record is available to all in primary care, such as the district nurses and GPs and the out of hours services. It is designed to give health care staff quicker information about the person, their medications, allergies and long term conditions. Patients can access their record through a secure website.
Last updated on October 4, 2011