The purpose of this guide is to explain how the care planning process works within Person Centred Software.
The 3-stage process is as follows:
Stage 1: Assessment tools
Stage 2: Initial and Current assessments
Stage 3: Care Plans
If documents are completed in this order, the system can pull through information at each stage making the process a lot smoother for staff completing. Please check that all relevant risk assessments have been completed before proceeding to the steps below
In mCare:
1. Select a service user.
2. Select the Care planning drop down at the top right of the screen. This is where you can find the three stage Care Planning process.
3. Select Initial assessment.
There are 5 main sections to the Initial assessment:
• Cognition
• Psychological
• Physical
• Social
• End of life
4. There are 2 symbols that can be seen on the yellow heading bars:
• The head and shoulders icon.
Any information written into this box will automatically populate the Who I am document. This can be accessed on the handset as well as on the computer.
• The blue information circle. This tells you that there is some information already held in the system from an assessment tool, that may be relevant to this section of the Initial assessment.
Clicking on the blue information circle opens up a drop down, showing the information available.
5. There are two ways to pull this information through to the Initial assessment.
The first of these is to click the Auto fill blanks from informs button at the top of the screen.
This will import all the relevant information from the Assessment tools completed in the previous step.
6. If you use this feature you will need to edit each section to make it more personalised for the individual and easy for staff to read. To do this you will need to:
• Remove any duplicated information,
• Explain any ambiguous statements,
• Remove anything that doesn’t apply to the service user,
• Add in any other relevant information.
Remember that the text that populates the boxes is only a suggestion. It should always be rewritten, removed, or reworded as necessary to make it person centred. Essentially an auditor or inspector should be able to look at the Initial assessment and see that it is unique to the individual it belongs to.
Text may be edited by clicking into the text box and editing as you would any other document.
7. Alternatively, statements from Assessment tools may be added individually to the Initial assessment.
To do this, first click the pale blue box underneath the yellow header bar.
Then click the blue information circle and select the statement that you would like to include in the Initial assessment.
Then click the blue information circle and select the statement that you would like to include in the Initial assessment.
8. To add information to an empty section, click the light blue box under the yellow header bar. You can now free type the information and will usually see a prompt of some things that could be included.
Again, these are only suggestions, you should add whatever is relevant for the individual.
9. Remember to save your work as you go along by pressing the green save button at the top of the screen. You can come back and add move information later.
When you save for the first time, you will see this message. This indicates that the system will now link information from Stage 1 (Assessment tools) and from Stage 2 (Initial and Current assessment) to Stage 3 (Care plans). This saves you some manual work at the next stage.
Click Save and create links
10. There will now be additional symbols on some of the yellow header bars.
The History symbol, when selected, shows information about who completed the section, date and time of completion and any changes to the information made.
The green tick shows how many sections of the Care plan have incorporated the information from the text box.
The grey text at the bottom of the box shows which sections they are.
11. At this point, additional information can still be added to the initial assessment.
• Make sure all boxes are completed, focusing on what the service user can do, and what they need support with at the current time.
• Try to include a balanced overview and add as much detail as needed.
• Don’t try to backdate the Initial assessment for existing service users, as that information will already be outdated. Instead complete the Initial assessment as a snapshot of their current situation.
12. Once all boxes have been filled, save the document as normal but then click the Complete button.
The yellow Initial assessment is now locked and can’t be edited, but the system has created a duplicate version called the Current assessment. This one is green.
It is the Current assessment that will be updated when the service user’s needs change; the Initial assessment will remain as it was when it was first completed.
For this reason, do not click the Complete button until you are sure that the Initial assessment is finished.
13. The Initial assessment may be viewed by clicking Show initial assessment.
Once you return to the Service user details screen, it can be accessed by clicking the Care planning button, and selecting Initial assessment from the drop down menu.
The Current assessment may now also be accessed from this menu. Now that Step 2 – Initial and current assessment is complete, we can move onto Step 3 – Care Plans. Help in completing this can be accessed in the separate guide.