PKB often gets requests from teams to create a treatment or proforma care plan that they can use with their patient cohort. This type of plan is completed regularly, as required, over a period of time while the patient is either going through treatment or receiving a form of rehab. These care plans can often be lengthy with lots of information and content. PKB has created a basic template that can be adapted to suit your patient cohort and team specialty.

Have a look through the template and let your Success PM know what content (text and information) you want to add.

What’s Contained in a PKB Care Plan?

PKB will always show in the care plan any diagnoses, allergies, and medications that have been entered in the patient record. The main body of the plan includes an action plan. The action plan can include information on the patient's care, health goals, and advice on monitoring their conditions. (Including video or web links). Key symptoms and measurements can also be selected to track and display for the patient.

Long Care Plan Template

At the top of the care plan, there are links to the different sections within the plan, and unlike a shorter care plan, after each section, there is a button that takes you to the top of the plan again (back to top). This care plan is divided into 10 clear sections. Each section is clearly defined by the black borderline and within each section, the font is clear and text spaced out with the intention that the content is easy to read and digest.

ACL Reconstruction Proforma Care Plan Template

.form-group {width: 100%; !important}

.cpwhiteBox {background-color:#ffffff; padding:15px; margin-bottom:10px; margin-top:10px; border-radius: 10px; border: 3px solid #014151;}

</style>

<ul>

<li style="list-style:inherit; margin-left: 15px;"><a href="#1">Screening and Consent tool</a></li>

<li style="list-style:inherit; margin-left: 15px;"><a href="#1a">Occupational Therapy Assessment</a></li>

<li style="list-style:inherit; margin-left: 15px;"><a href="#2">Stage 1 Initial Assessment</a></li>

<li style="list-style:inherit; margin-left: 15px;"><a href="#3">Stage 2 Assessment</a></li>

<li style="list-style:inherit; margin-left: 15px;"><a href="#4">Stage 3a Assessment</a></li>

<li style="list-style:inherit; margin-left: 15px;"><a href="#5">Stage 3b Assessment</a></li>

<li style="list-style:inherit; margin-left: 15px;"><a href="#6">Stage 4 Assessment</a></li>

<li style="list-style:inherit; margin-left: 15px;"><a href="#7">Stage 5 Assessment</a></li>

<li style="list-style:inherit; margin-left: 15px;"><a href="#8">Stage 6 Assessment</a></li>

<li style="list-style:inherit; margin-left: 15px;"><a href="#9">Stage 7 (4 months) Assessment</a></li>

<li style="list-style:inherit; margin-left: 15px;"><a href="#10">Stage 8 (5 months) Assessment</a></li>

<li style="list-style:inherit; margin-left: 15px;"><a href="#11">Stage 9 (6 months) Assessment</a></li>

<li style="list-style:inherit; margin-left: 15px;"><a href="#12">Return to Sport (9 month) Assessment</a></li>

</ul>

</div>

<h1>Screening/Consent Checklist Tool, Physiotherapy OPD/Group Rehabilitation London Road Community Hospital (UHDB Trust)</h1>

<h2>1 Consultation Types</h2>

<p><b>Telephone consultation (T/C)</b> allows a full history of your condition to be taken. There may be some capacity to assess movement & function, but there is the possibility of missing some clinical detail. There is no risk of being infected with coronavirus with this consultation type.</p>

<p><b>Video consultation (T/M)</b> allows a partial, but not full physical examination and there is the possibility of missing some clinical detail. You will need Google chrome or safari and a microphone and camera. There is no risk of being infected with coronavirus with this consultation type.</p>

<p><b>Face to face consultation (F2F)</b> involves coming into the hospital for Physiotherapy/OT. This will allow a full physical assessment and treatment, if necessary. The F2F process is not risk free; contact with your therapist and possibly other individuals increases the risk of being infected with coronavirus. We have strict infection control measures in place to minimise this risk.</p>

<p>Having heard the pros and cons of each consultation type do you prefer a telephone consultation (T/C), a video consultation (T/M) or a face to face consultation (F2F).</p>

<label for="cp_consultType"><h3>Patient choice of consultation</h3></label>

</div>

<option value="--">Select</option>

<option value="Telephone consultation (T/C)">Telephone consultation (T/C)</option>

<option value="Video consultation (T/M)">Video consultation (T/M)</option>

<option value="Face to face consultation (F2F)">Face to face consultation (F2F)</option>

</select>

</div>

</div>

<h2>2 Covid-19 Screening</h2>

<p>Have you or your household members experienced any of the following symptoms over the past 14 days?</p>

<label for="cp_highTemp"><h3>High Temperature</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

<label for="cp_contCough"><h3>New continuous cough</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

<label for="cp_tasteChange"><h3>Change in taste/smell </h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

<h2>3 Covid-19 Risk Screening</h2>

<label for="cp_3a"><h3>a) Have you received a letter from the NHS or been told by your GP that you are high risk? Are you shielding? Such as organ transplant, severe lung condition etc. <b>HIGH RISK</b></h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

<label for="cp_3b"><h3>Are or have you any of the following? Age ≥ 70, BMI ≥ 40, diabetes, pregnancy, liver, heart or chronic kidney disease, lung condition (non-severe), brain/nervous system condition, condition that increases infection or taking immunosuppresants <b>MODERATE RISK</b></h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

</div>

<option value="--">Select</option>

<option value="Have none of the above">Have none of the above</option>

</select>

</div>

<h2>4 Informed Consent:</h2>

<h3>(a) Infection Control/Risk with Covid-19</h3>

<p>Explain the safety and infection control measures in place to minimise risk with a F2F consultation.</p>

<label for="cp_infectionUnderstand"><h3>Select to confirm understood</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

<p><i>On attending your appointment, you will have a temperature check and you will be given a mask to wear during your consultation. Your therapist will also be wearing personal protective equipment. </i></p>

<p><i>We adhere to the Hospital Trust's current infection control measures.</i></p>

</div>

<p>Explain the risks of contracting Covid-19</p>

<label for="cp_covidUnderstand"><h3>Select to confirm understood</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

<p><i>Despite these measures, the risk of infection is still present as people may be infected & spread it to others without knowing.</i></p>

<p><i>If you become infected you could become seriously unwell or die.</i></p>

</div>

<h3>(b) Clinical Risk/informed choice</h3>

<label for="cp_highRisk"><h3><b>HIGH RISK</b> - You have been identified as being extremely clinically vulnerable. Knowing the risks and infection control measures in place, do you still prefer to have a F2F consultation</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

<label for="cp_moderateRisk"><h3><b>MODERATE RISK</b> - You have been identified as being clinically vulnerable. Knowing the risks and infection control measures in place, do you still prefer to have a F2F consultation?</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

<label for="cp_lowRisk"><h3><b>LOW RISK</b> - You have been identified as having low clinical vulnerability. Knowing the risks and infection control measures in place, are you happy with having a F2F consultation?</h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

<h3>(c) Questions or Concerns</h3>

<label for="cp_q4Concerns"><h3>Do you have any questions or concerns? </h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

<label for="cp_q4concernsAddressed"><h3>Have the questions/concerns been addressed? </h3></label>

</div>

<option value="--">Select</option>

</select>

</div>

<label for="cp_validation"><h3>Validate choice of consultation - </h3></label>

<textarea class="form-control" name="cp_validation" id="cp_validation" rows="10" style="width: 100%;">Name _______________________________ consents to a _____________ consultation</textarea>

</div>

<label for="cp_completedBy1"><h3>Completed by:</h3></label>

</div>

</div>

<label for="cp_date1"><h3>Review date:</h3></label>

</div>

</div>

<label for="cp_Time1"><h3>Review time:</h3></label>

</div>

</div>

<h1>Occupational Therapy Assessment</h1>

<h2>Employment details</h2>

<label for="cp_occupation"><h3>Occupation:</h3></label>

</div>

</div>

<label for="cp_employer"><h3>Employer:</h3></label>

</div>

</div>

<label for="cp_shiftPattern"><h3>Normal hours/shift pattern:</h3></label>

</div>

</div>

<label for="cp_jobDescription"><h3>Description of job role:</h3></label>

</div>

<label for="cp_dutiesAvailable"><h3>Potential light duties available:</h3></label>

</div>

<label for="cp_absenceStart"><h3>Start of sickness absence date:</h3></label>

</div>

</div>

<label for="cp_noteExpiry"><h3>Sick note/fit note expiry date:</h3></label>

</div>

</div>

<label for="cp_returnDate"><h3>Any plan/date for return to work:</h3></label>

</div>

</div>

<h3>If employed:</h3>

ACL Reconstruction Care Plan

What’s Contained in a PKB Care Plan?

Long Care Plan Template

ACL Reconstruction Proforma Care Plan Template