Every formal HNA should result in a care plan that summarises the issues and concerns identified as a priority for the person. It should also record the goals, actions and approaches jointly agreed to address them.
This should include documentation of any issues or concerns that were felt to be addressed immediately through the assessment as well as any actions to be taken:
- by the person (eg, follow-up signposting) or
- the professional (eg, referrals to support services) after the assessment.
It should be developed in partnership with the person, and the person should hold their HNA and care plan so that they can share it with their carers, family and friends if they wish.
Reviewing the content in the care plan (eg, when conducting audits) can give an indication of whether the HNA and Care Planning was good quality (rather than simply tick box exercises). Patients should also be asked for feedback as to how useful or valuable they find the process. Together, this can give professionals confidence in the quality and effectiveness of HNAs and Care Planning.
Holistic needs care plan should:
- Focus on what is important to the person living with cancer.
- Prioritise concerns
- Enable individualised care
- Enable person centred care
- Support self management
- Contribute to quality care
