The diabetes care plan includes the individual goals, methods and monitoring related to the care. As the person with diabetes, you are the expert on your own health and daily care. You carry most of the responsibility for your daily care. Self-management means the decisions and actions you take on a daily basis, such as tracking your blood sugar level, implementing insulin therapy and other drug therapy as well as ensuring a proper diet and sufficient exercise. The personal health and care plan is a tool and support which help you to manage your diabetes.
The starting point of the health and care plan is your own personal needs, goals and resources and the plan is always made in collaboration with you. The plan includes the key conditions and complications as well as their treatment and treatment goals. If necessary, it also describes your ability to function. The health and care plan helps all of the professionals involved in your care get an overall view of the situation and ensure that the care meets your individual needs and preferences.
The care plan is part of your patient record. It is drawn up during the early stages of diabetes and updated as required at each meeting. The care plan is a general plan, which informs the care and supports self-management. It helps ensure the continuity of care and guidance.
The care plan is drawn up jointly at your treatment centre, although the attending physician carries the overall responsibility for it. The members of the multi-professional care team contribute to the drawing up of the plan as well as the monitoring of its implementation as required.