The Purple Book

Care Plans

Heart Failure

The specialist heart failure MDT should write a summary for each person with heart failure that includes:

1. diagnosis and aetiology
2. medicines prescribed, monitoring of medicines, when medicines should be reviewed and any support the person needs to take the medicines
3. functional abilities and any social care needs
4. social circumstances, including carers' needs.

The summary should form the basis of a care plan for each person, which should include:

1. plans for managing the person's heart failure, including follow-up care, rehabilitation and access to social care
2. symptoms to look out for in case of deterioration
3. a process for any subsequent access to the specialist heart failure MDT if needed
4. contact details for
   1. a named healthcare coordinator (usually a specialist heart failure nurse)
   2. alternative local heart failure specialist care providers, for urgent care or review.
   3. additional sources of information for people with heart failure.