CEP-12 Care Plan

References

Wireframes

https://www.figma.com/design/wE4aB7XELuASk2dKBUKToZ/Care-Plan-Wireframe?node-id=0-1&t=Av3ebeUiCTmRoAan-1

Implementation Overview

A Care Plan is a coordinated map of healthcare activities designed to address specific patient health concerns. At its core, it's an organized collection of intended activities that healthcare providers plan to perform, are performing, or have performed for a patient.

To visualize better, lets create a django model for care plan

class CarePlan(EMRBaseModel):
    status = Int(choices) # draft|active|completed|on-hold|cancelled|entered-in-error|unknown
    intent = Int(choices) # proposal|plan|order|option|directive
    title = CharField()
    description = TextField()
    start_date = DateField()
    end_date = DateField()
    patient = FK(Patient)
    encounter = FK(Encounter)
    custodian = FK(FacilityOrganization) # wont use if we use encounter
    addresses = JSONField() # (many) seeing we are storing snomed codes as json everywhere else
    notes? = TextField()

The care plan will have activities associated with it. These will be done to accomplish the goals in a care plan.

class Activity(EMRBaseModel):
    care_plan = FK(CarePlan)
    performed = BooleanField()
    # only one of the following FKs will be filled
    activity_task = FK(Task)
    activity_medication_request = FK(MedicationRequest)
    activity_service_request = FK(ServiceRequest)

I am not very sure about how the Task and ServiceRequest would look like. We can directly connect these models to the care plan instead of having the Activity model if it is more feasible.

A goal will be used to track the targets that must be achieved for the duration of the care plan.

A Goal in health care services delivery is generally an expressed desired health state to be achieved by a subject of care (or family/group) over a period or at a specific point of time. This desired target health state may be achieved as a result of health care intervention(s) or resulting from natural recovery over time.

class Goal(BaseModel):
    care_plan = FK(CarePlan)
    created_by = FK(User)
    lifecycle_status = IntegerField(choices=GoalLifeCycle.choices) #proposed | planned | accepted | active | on-hold | completed | cancelled | entered-in-error | rejected
    achievement_status = Int(choices) # in-progress | improving | worsening | no-change | achieved | sustaining | not-achieved | no-progress | not-attainable
    is_continuous = BooleanField()
    priority = IntegerField(choices=Priority.choices) # low | medium | high
    description = TextField()
    start_date = DateField()
    requested_by_patient = BooleanField()
    notes = FK(Annotation[]) or TextField # No idea what to use here
    outcome = FK(Observation[]) # I think we are already working on observations?
    targets = JSONfield([
        # will hold array of objects of the parameters of the patient we want to achieve, and what type of achievement it will be ("ratio", "range", "exact", etc.)
    ])
    permitted_groups = oneToMany(Organizations) # to specify if an organization can update the goal or not.

Now, a goal would also need status checks. Status checks will be just updates to a singular goal across time and would be done by the assigned physician/nurse.

class GoalUpdate(BaseModel):
    created_by = FK(User)
    goal = FK(Goal)
    target_values = JsonDict()
    notes = TextField()

    def save ():
    # the save method will check values, compare it with the last update, and then determine the parent Goal's achievement_status.

The goal update will smartly update the goal’s status depending on the measured values. If this is not optimal, we can default to manually setting the goal status. Setting a goal to “not-attainable” will mean the goal should not have any updates done to it. If a goal update value matches the required goal target, the goal status changes to “achieved”. If the target is not met before the due date, the status becomes “not-achieved.” Similarly, other statuses can be smartly determined by comparing the latest updates with previous ones.

These models will help us better visualize and form a base understanding of how this will be integrated into CARE.

User Story: Managing a Patient's Care Plan for Fever

As a doctor,
I want to create and manage a comprehensive care plan for a patient with fever,
so that the patient's condition can be effectively monitored, treated, and resolved.

1. Care Plan Creation

The doctor creates a "Fever Management Plan" to address the patient's condition.
The care plan includes:
- Prescription for medication.
- Regular monitoring of vital signs (e.g., temperature).
- Ordering necessary lab tests.
- Establishing a goal for recovery.

2. Setting a Goal

The doctor sets a goal for the care plan, such as:
- "Reduce patient temperature to below 37°C within 48 hours."
The goal is added to the care plan and linked to relevant activities.

3. Goal Updates

The doctor tracks progress toward the goal by recording updates based on patient metrics (e.g., temperature readings).
Each update includes:
- Date and time.
- Current value of the metric (e.g., "Temperature: 38.5°C").
- Comments, if necessary.
The goal's progress is automatically visualized.

4. Visualizing Goal Progress

The doctor views a time-series graph showing the patient's progress toward the goal:
- X-axis: Time (e.g., hours since care plan creation).
- Y-axis: Goal metric (e.g., temperature in °C).
The graph provides a clear view of whether the goal is being achieved.

5. Medication Prescription

The doctor prescribes Paracetamol for fever management.
The care plan records this as a planned activity under MedicationRequest.

6. Vitals Monitoring Task

The doctor initiates a task for temperature monitoring.
This is added to the care plan as a planned activity under Task.

7. Lab Test Request

The doctor orders a blood test to investigate underlying causes.
This is recorded as a planned activity under ServiceRequest in the care plan.

8. Executing Activities

Medication Administration:
- The doctor starts the prescribed medication regimen.
- The MedicationRequest status is updated to active.
- Administration details, such as dosage and frequency, are recorded in the patient's progress.
Temperature Monitoring:
- The doctor begins temperature monitoring.
- The Task status is updated to in-progress.
- Recorded temperature readings are added to the patient's progress.
Lab Test:
- The doctor ensures the blood test is performed.
- The ServiceRequest status is updated to in-progress.
- Completion of the test (e.g., blood sample collection) is recorded in the patient's progress.

9. Completing Activities

The doctor marks the medication course as completed in the care plan.
Temperature monitoring is concluded, and the Task status is updated.
Lab test results are received, and the ServiceRequest is marked as completed.

10. Printing the Care Plan

The doctor can generate a print-friendly version of the care plan.
The printed care plan includes:
- The list of activities.
- The patient's progress.
- Goals and goal updates.
- Final status of the care plan.

11. Finalizing the Care Plan

The doctor reviews all activities to ensure they have been executed successfully.
The care plan's overall status is updated to completed, reflecting the resolution of the patient's condition.

Outcome

The care plan effectively coordinates medication, monitoring, and diagnostic activities to ensure comprehensive treatment of the fever.
Goals and progress tracking provide clear milestones and insights into the patient's recovery.
The doctor has access to a visualized timeline of progress and a print-ready document for recordkeeping or sharing with the patient.

Nurse Flow

As a nurse,
I want to view the care plan's goals and update progress toward them, as well as update the status of assigned tasks,
so that I can ensure accurate tracking of the patient’s recovery and contribute to effective care delivery.

1. Viewing Goals

The nurse can access the care plan to view all created goals.
Each goal displays:
- Goal description (e.g., "Reduce patient temperature to below 37°C within 48 hours").
- Current progress (e.g., "Temperature: 38.2°C").
- Visualization of progress (time-series graph).
- Status (e.g., on track, at risk, or achieved).

2. Adding Goal Updates

The nurse can add updates to goals based on patient assessments.
Each update includes:
- Date and time of the update.
- Updated metric value (e.g., "Temperature: 37.8°C").
- Optional comments (e.g., "Patient responded well to medication").
The update automatically:
- Updates the goal's progress tracking.
- Refreshes the time-series graph with the new data point.
The system validates updates to ensure they align with the goal's metrics.

3. Viewing Assigned Tasks

The nurse can view all tasks associated with the care plan.
Each task displays:
- Task name (e.g., "Temperature Monitoring").
- Current status (e.g., not started, in progress, completed).
- Task details, such as:
  - Scheduled start and end times.
  - Instructions or steps for completion.

4. Adding Task Updates

The nurse can update the status of a task as work progresses:
- Update options include:
  - Start Task (changes status to in progress).
  - Complete Task (changes status to completed).
  - Add a comment or observation related to the task (e.g., "Temperature reading recorded").
For tasks requiring data entry (e.g., temperature monitoring):
- The nurse records the relevant data (e.g., "Temperature: 37.5°C").
- Data is automatically linked to both the task and the relevant goal.

5. Reviewing Progress

The nurse can view a summary of:
- Recent goal updates.
- Recent task updates.
This provides a quick overview of the patient’s current status.

6. Communication with the Doctor

The nurse can flag specific updates or issues for the doctor to review, such as:
- Metrics not improving as expected.
- Challenges in completing assigned tasks.
Notifications are sent to the doctor for flagged items.

Outcome

The nurse can efficiently track and update patient goals and tasks, ensuring accurate and timely information is available in the care plan.
Goal updates and task statuses contribute to a complete picture of the patient’s recovery progress.
Clear communication and data sharing between the nurse and doctor enhance the quality of care.

Sample Data

Care Plan

{
  status: "active",
  intent: "plan",
  title: "Care Plan",
  description: "Patient had c/o. General weakness. Patient is conscious , oriented and bed ridden(peg tube (+). Patient is obeying commands .Vitals checked ( BP:130/80 mmhg , Pulse:84/mint, Spo2:98% on Room air).  When communicating with a patient , face patient , & maintain eye contact
& speak slowly.
- Attempt to anticipate patients' needs - it helps to prevent frustration &
anxiety
- Prevent repeated asking of same questions ,patient feels angry when we
cannot understand what he is saying and try to distract him with easy or familiar
questions.
- When communicating with a patient , face patient , & maintain eye contact
& speak slowly.
- Attempt to anticipate patients' needs - it helps to prevent frustration &
anxiety
- Prevent repeated asking of same questions ,patient feels angry when we
cannot understand what he is saying and try to distract him with easy or familiar
questions .
● Monitor Vital Signs :-
- Blood pressure to be monitored monthly or biweekly .
- Position with head slightly elevated & in neutral position helps to reduce
arterial pressure by promoting venous drainage & may improve cerebral
perfusion
- Maintain bedrest , provide a quiet & relaxing environment , restrict visitors
& activities (continue stimulation /activity can increase intracranial
pressure)
",
  start_date: "2022-10-10",
  end_date: "2022-10-20",
  patient: "... from patient model",
  encounter: "... from encounter model",
  custodian: "... from facility model",
  addresses: [
    {
      code: "code",
      display: "Advanced Parkinson's Plus Syndrome",
      system: "snomed",
    },
    {
      code: "code",
      display: "Progressive Supranuclear palsy",
      system: "snomed",
    },
    {
      code: "code",
      display: "Probable aspiration pneumonia",
      system: "snomed",
    },
    {
      code: "code",
      display: "Diabetes mellitus",
      system: "snomed",
    },
    {
      code: "code",
      display: "Hypothyroidism",
      system: "snomed",
    },
    {
      code: "code",
      display: "Hypertension",
      system: "snomed",
    },
    {
      code: "code",
      display: "CAD- s/p.CABG(2012)",
      system: "snomed",
    },
    {
      code: "code",
      display: "H/O Tubular adenoma with high grade dysplasia s/p Polypectomy(2014)",
      system: "snomed",
    }
  ],
  notes: "",
}

Activities

[
  {
    "care_plan": "... from care plan model",
    "performed": true,
    "activity_task": "Check Vitals (From task model)"
  },
  {
    "care_plan": "... from care plan model",
    "performed": true,
    "activity_task": "head to foot assessment"
  },
  {
    "care_plan": "... from care plan model",
    "performed": true,
    "activity_task": "give psychological support"
  },
  {
    "care_plan": "... from care plan model",
    "performed": true,
    "activity_task": "Explain condition to wife"
  },
  {
    "care_plan": "... from care plan model",
    "performed": false,
    "activity_task": "Provide good personal hygiene"
  },
  {
    "care_plan": "... from care plan model",
    "performed": false,
    "activity_task": "Provide comfortable positions with the help of pillows"
  },
  {
    "care_plan": "... from care plan model",
    "performed": false,
    "activity_task": "Proper PEG tube Feed & Care"
  }
]

Goals

[
  {
    "care_plan": "... from care plan model",
    "created_by": "... from user model",
    "lifecycle_status": "active",
    "achievement_status": "improving",
    "is_continuous": true,
    "priority": "low",
    "description": "provide total care to the patient",
    "start_date": "2022-10-10",
    "requested_by_patient": false,
    "targets": [],
    "permitted_groups": ["... from organization model"]
  },
  {
    "care_plan": "... from care plan model",
    "created_by": "... from user model",
    "lifecycle_status": "active",
    "achievement_status": "in-progress",
    "is_continuous": true,
    "priority": "low",
    "description": "maintain the patient's comfort and dignity throughout their illness",
    "start_date": "2022-10-10",
    "requested_by_patient": false,
    "targets": [],
    "permitted_groups": ["... from organization model"]
  },
  {
    "care_plan": "... from care plan model",
    "created_by": "... from user model",
    "lifecycle_status": "active",
    "achievement_status": "in-progress",
    "is_continuous": true,
    "priority": "low",
    "description": "provide emotional and spiritual support to the patient and their family",
    "start_date": "2022-10-10",
    "requested_by_patient": false,
    "targets": [],
    "permitted_groups": ["... from organization model"]
  },
  {
    "care_plan": "... from care plan model",
    "created_by": "... from user model",
    "lifecycle_status": "proposed",
    "achievement_status": "no-change",
    "is_continuous": true,
    "priority": "low",
    "description": "respect the caregivers preferences for end-of-life care",
    "start_date": "2022-10-10",
    "requested_by_patient": false,
    "targets": [],
    "permitted_groups": ["... from organization model"]
  },
  {
    "care_plan": "... from care plan model",
    "created_by": "... from user model",
    "lifecycle_status": "active",
    "achievement_status": "no-change",
    "is_continuous": true,
    "priority": "medium",
    "description": "daily oral care twice a day",
    "start_date": "2022-10-10",
    "requested_by_patient": false,
    "targets": [],
    "permitted_groups": ["... from organization model"]
  },
  {
    "care_plan": "... from care plan model",
    "created_by": "... from user model",
    "lifecycle_status": "active",
    "achievement_status": "no-change",
    "is_continuous": true,
    "priority": "medium",
    "description": "Vaselin application lips for drying lips",
    "start_date": "2022-10-10",
    "requested_by_patient": true,
    "targets": [],
    "permitted_groups": ["... from organization model"]
  },
  {
    "care_plan": "... from care plan model",
    "created_by": "... from user model",
    "lifecycle_status": "active",
    "achievement_status": "no-change",
    "is_continuous": true,
    "priority": "medium",
    "description": "Daily sponge baths needed twice",
    "start_date": "2022-10-10",
    "requested_by_patient": false,
    "targets": [],
    "permitted_groups": ["... from organization model"]
  },
  {
    "care_plan": "... from care plan model",
    "created_by": "... from user model",
    "lifecycle_status": "proposed",
    "achievement_status": "no-change",
    "is_continuous": false,
    "priority": "high",
    "description": "Patient on Airbed to prevent Pressure sore",
    "start_date": "2022-10-10",
    "requested_by_patient": false,
    "targets": [],
    "permitted_groups": ["... from organization model"]
  },
  {
    "care_plan": "... from care plan model",
    "created_by": "... from user model",
    "lifecycle_status": "proposed",
    "achievement_status": "no-change",
    "is_continuous": false,
    "priority": "high",
    "description": "Provide Side rails for bed (risk of trauma)",
    "start_date": "2022-10-10",
    "requested_by_patient": false,
    "targets": [],
    "permitted_groups": ["... from organization model"]
  }
]

References​

Wireframes​

Implementation Overview​

User Story: Managing a Patient's Care Plan for Fever

1. Care Plan Creation​

2. Setting a Goal​

3. Goal Updates​

4. Visualizing Goal Progress​

5. Medication Prescription​

6. Vitals Monitoring Task​

7. Lab Test Request​

8. Executing Activities​

9. Completing Activities​

10. Printing the Care Plan​

11. Finalizing the Care Plan​

Outcome​

Nurse Flow​

1. Viewing Goals​

2. Adding Goal Updates​

3. Viewing Assigned Tasks​

4. Adding Task Updates​

5. Reviewing Progress​

6. Communication with the Doctor​

Outcome​

Sample Data​

Care Plan​

Activities​

Goals​

References

Wireframes

Implementation Overview

1. Care Plan Creation

2. Setting a Goal

3. Goal Updates

4. Visualizing Goal Progress

5. Medication Prescription

6. Vitals Monitoring Task

7. Lab Test Request

8. Executing Activities

9. Completing Activities

10. Printing the Care Plan

11. Finalizing the Care Plan

Outcome

Nurse Flow

1. Viewing Goals

2. Adding Goal Updates

3. Viewing Assigned Tasks

4. Adding Task Updates

5. Reviewing Progress

6. Communication with the Doctor

Outcome

Sample Data

Care Plan

Activities

Goals