My Health ManagementPlan

My Health Management Plan aims to:

  • Help you manage your health and care as well as possible
  • Helps you and the medical professionals, i.e. doctors and nurses, and others who may be involved with your care to work together with you to know about your health condition(s) and what is important to you.
  • Provide information about your condition, your medication and your preferences in a convenient form which can be available should you need to visit a hospital or a surgery other than your usual one (e.g. who do not have access to your GP notes)
  • Help everyone involved in your health to know what your goals are over the next 12 months.

Created:

Printed:

The plan contains all the information about your condition(s), your treatment and medication and the details of those people involved in your healthcare. It also contains personal information about your preferences, your hopes and wishes, your likes and dislikes and any things you would like to achieve withregard to your health. It will also give you an opportunity to share your thoughts on how and where you would like to be looked after if you were ever too ill to be able to tell us.

This plan will be kept by you so you are able to share this information with any healthcare professional involved in your care. This plan will contain confidential information about you and it is important you do not lose it.

Don’t forget to bring your My Health ManagementPlan to ALL of your health and care appointments

About Me:

My Name: / What I like to be called:
Address: / DOB:
Who lives at home:
Work:
Contact Details:
Phone:
Mobile:
Email: / Preferred means
of contact: / Communication needs:
Religion / Ethnic Background: / My preferred language is:
My NHS number: / GP Name, Address , Tele number

My next of kin and other contacts:

Name / Relationship to me / Contact details
Next of kin:

My main carer/supporter and others involved in my care (if appropriate):

Name / Relationship to me / Contact details
Main carer/supporter:
This is the care my carer provides to me:
These are the services my carer accesses for support / e.g. Carer’s in Herts or Crossroads
My long term conditions are: / Normal for me:
Risk of Falls and Frailty
Falls risk assessment:
My frailty score is:
My Independence e.g. what is you mobility like?
Issues that make things harder for me at times:
Vision
Hearing
Reading or writing
Transport
Pain

What is important information about my beliefs and culture?

(Likes/dislike to help inform health professional and others about how I like to be treated)

What is important to me?

Consider diet, exercise, lifestyle & wellness goals

My Medication

(You may wish to attach a list of your current medications to this care plan. Please ask your pharmacist or GP to provide you with a recent copy).

Medication / Dose / Format eg. tablet, syrup, injection etc / I take this medicine because it will ( eg. help prevent me from having a heart attack)

My allergies and drug reactions are:

Drug Name / Reaction (e.g. rash or diarrhoea)

This is the support I need with managing my medicines:

Concerns I have about my medication that I want to discuss with my doctor:

Date of last review:Date of next review:

Contact details for pharmacist:

Name:
Location: / Phone Number:

What do I do if I become poorly?

(sudden change in my health)

Signs and symptoms / Action to be taken / Who to contact? / Contact details

My care team(list key people - e.g. care co-ordinator, nurse)

Name of person/organisation / How they will/can help me? / Contact details

My Future Care

Treatment Escalation Plan
Preferred Place of Care
Treatment Escalation Plan
DNARCPR Status

Advance Planning: If my condition progresses or suddenly deteriorates, these are the arrangements that I would like to be considered:

My preferences and priorities for future care when I am ill or towards the end of life:

I can confirm I have the following documentation:

Document / Yes / No / Where these documents are kept
Advance Directive/Living Will
Lasting Power of Attorney(Finances)
Lasting Power of Attorney (Welfare)
Do Not Attempt Cardiopulmonary Resuscitation Order signed by a doctor
Other Care or Support Plan

Questions I want to ask my health professional at my next appointment and other relevant information:

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My Goals & Action Plans

Making one or two changes to your everyday life can make a dramatic difference to your health. These changes may include changing your diet, stopping smoking, doing more exercise or drinking less alcohol. Answering the following questions will help you identify and achieve these changes. If you have been given this as part of your Long Term Condition review, please complete the below and bring it when you attend your appointment.

Overview
Summary:
What are the most important things to you at the moment?
These are some things that people sometimes want to talk about. Circle any that are important to you:
Sleep
Medication
Monitoring my health
Healthier eating
Pregnancy and contraception
Driving
Work / benefits / money / Feeling low, stressed or lonely
Giving up smoking
My day-to-day health
Alcohol
Mobility
Breathing
Pain / Physical activity
Relationships/sex life
My future health
Help for your carer
Tiredness
Help with your social needs
Appetite
What else would you like to discuss?
Goal Setting
What do you want to work on?
What do you want to achieve?
How will you know if you’re successful?
How important is it to you?
Not important / 1 2 3 4 5 6 7 8 9 10 / Very important
Target Values / Previous / Current / Target
1 / HbA1c / No target set
2 / Blood Pressure / / / 100/80 / No target set/
3 / Total Cholesterol / No target set
4 / Weight / 50 Kg, 08/02/17 / 50 Kg, 08/02/17 / No target set
Action Planning
What exactly are you going to do?
What might stop you and what can you do about it?
Who can help you?
How confident do you feel?
Not confident / 1 2 3 4 5 6 7 8 9 10 / Very confident
Your Long Term Condition Review Appointment Summary
Use this section to summarise the conversations you have at your appointment and the plan you agree.
Your care planning appointment was with: / Date:
Summary of the conversation:
Follow up / Review of goal/action plan:
When: Where:

Additional Information

For further Information on a range of other support services I can contact Herts Help on 0300 123 4044 (Mon – Friday 8am-6pm)

NHS Choices: good place to start when looking for trusted health information.

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My Advance Decision to Refuse Treatment

This is my Advance Decision to Refuse Treatment in which I am specifying in advance which treatments I do not want in the future, should I lose mental capacity and can no longer consent to or refuse treatment.

This Advance Decision to Refuse Treatment replaces any previous advance decision I have made

I wish to refuse the following specific treatments which may or may not be life sustaining even if my like is at risk / In these circumstances

Record of discussion

Name:Date of Birth:

Details of the discussion:

Statement of Intent

Ibeing of present mind; wilfully and voluntarily execute this Advance Decision to Refuse Treatment, to assure that, during periods of incapacity, my choices regarding my health care will be carried out despite my inability to make informed decision on my own behalf. I intend this document to take precedence over all other means of ascertaining my intent during such periods of incapacity.

To the extent, if any, that this document would not be considered valid in law, it is my desire that it is considered a statement of my wishes, and that it is accorded the greatest possible legal weight and respect. Understand that this decision will become active and take effect upon my incapacity.

Any blanks in this document should not affect its validity in any way. I intend all completed sections are followed.

I am aware that this Advance Decision to Refuse Treatment will be valid from the date of signing. I will be given the opportunity to renew, amend or cancel it one year from now. If I am incapacitated at this time, then my Advance Decision to Refuse Treatment will remain in place until I become well enough to make decision.

I may withdraw this decision at anytime by notifying my doctor or health and social care professionals in writing of my intention to do so.

My signatureDate:

I confirm that this form has been completed by the above named person and I am acting as a witness to their signature

Witness

Name: / Signature / Date:
Address:
Telephone: / Mobile:

Person to be contacted to discuss my wishes

Name:
Relationship
Address:
Telephone:

I have discussed this with (name of health professional)

Name:
Job title:
Telephone:
Email:

I give permission for this to be discussed with my relativesYESNO 

(pleasetick)

People who have been told about this Advance

Decision to Refuse Treatment

The following list identifies people who have been given a copy of this Advance Decision to Refuse Treatment.

Please write in the names and contact details of people who have been told about this Advance Decision to Refuse Treatment, and have been given a copy.

Name / Relationship / Address / Telephone

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