Patient personalised clinical management plan

Patient personalised clinical management plan


On discharge from hospital, all heart failure patients should receive a summary that includes:

  1. Contact details of the heart failure team (hospital/community/urgent care centre) and information on how to access them in event of queries or deterioration;
  2. Their diagnosis and the potential cause of their deterioration;
  3. Current medications, why they should take it and description of any monitoring required; and
  4. Follow up plans:

a. Individualised guidance on self-management, lifestyle and drugs not to take (e.g. NSAIDS);

b. Heart failure passport (paper copy or app) or similar (e.g. traffic light-based symptom monitor) - Click here for more information

c. Understanding of ‘sick day rules’; and

d. Assessment of functional abilities and social care needs.

Inform the patient that their clinical management plan is shared and is accessible with those professionals involved in care and those who maybe involved in care in case of an emergency/deterioration.

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(c) British Society for Heart Failure, 2022-
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