National Sharing of Care Plans for Patients with Chronic Diseases

Abstract

Care plans are an electronic tool available to all general practices as part of a strengthened effort for chronic patients. It ensures that the patient gains an overview and understanding of their treatment and care of their illness, and it provides the best basis for self-care. The health professional content in the care plan is defined based on relevant guidelines and recommendations from Danish Society for General Practitioners, the Danish Health Authority, etc. Practices can also use the care plan module to create an overview of their chronic patients in their own practice. Care plans provide an overview of the patient's illness and key values that are significant for treatment and monitoring. The Care plan module can be used as a dialogue tool with the possibility of supporting the patient's self-care and agreeing goals for the individual patient. Patients' care plans can be shared with healthcare professionals at hospitals and municipalities via the national eHealth infrastructure, which contributes to coherent and coordinated patient care.