44Meaning of multidisciplinary care plan

44 Meaning of multidisciplinary care plan

(1) For items 720, 722, 724, 726, 728 and 730 preparation of a multidisciplinary care plan means the preparation of a written plan describing all of the following matters:

(a) an assessment of the patient’s health care needs;

(b) an assessment of the kinds of treatment, health services and health care that the patient is likely to need;

(c) an assessment of any other kinds of services and care that the patient is likely to need;

(d) arrangements for giving the treatment, services and care referred to in paragraphs (b) and (c);

(e) management goals with which the patient agrees;

(f) arrangements to review the plan by a day specified in the plan.

For paragraph (c), other kinds of services and care may include home and community care service providers.

(2) Preparation of a plan also includes:

(a) discussing the preparation of the plan with the patient and the patient’s carer (if any, and if the practitioner considers it appropriate and the patient agrees); and

(b) telling the patient which persons will be included in the multidisciplinary care plan team; and

(c) recording the plan and the patient’s agreement to the preparation of the plan; and

(d) giving copies of relevant parts of the plan to persons who, under the plan, will give the patient the treatment, service and care mentioned in the plan; and

(e) offering a copy of the plan (and evidence of the contribution made to the plan by members of the team) to the patient and the patient’s carer (if any, and if the medical practitioner considers it appropriate and the patient agrees).