My Plan
My name is:
I like to be called:
If found please hand into a local GP surgery for safe return
What is My Plan?
Completing My Plan
My Plan is here to help you manage your health
and care as well as possible.
You can complete My Plan alone or by working
with someone involved with your care. That might
be a relative, carer, a friend, a key worker or a
health or social care professional. There will be
areas in the plan where you might need advice
from your health or care professional and we have
made this clear.
It aims to:
• Help you and the medical professionals i.e.
doctors and nurses, and others who may be
involved with your care to work together with you
to know what is important to you and your needs.
• Provide information about your condition(s),
medication, any allergies or medication reactions.
• Help you to know what you can do to manage
your health and care as well as possible,
including during those times when your health
worsens.
• Help everyone involved in your health and care
to know what your goals are over the next 12
months.
• Prevent you having to frequently tell your story to
different professionals.
My Plan also covers advance care planning, which
touches on the care you would like if you became
too ill to make decisions for yourself or any future
wishes you may have.
Take your My Plan to ALL of your health
and care appointments
My Plan can be completed at any stage of your
life. You are encouraged to complete only the
sections which are relevant to you and please
update it as your situation and priorities change so
those around you understand what is important to
you at that time.
What next?
My Plan is for you to keep and to share with any
health or social care professional involved in your
care. This may include if you visit your GP practice,
a hospital clinic, support worker or perhaps A&E
for an unexpected emergency. You and/or your
health or care professional can regularly update
your My Plan to reflect changes in your care and
treatment.
Don’t forget to add your name and what you
like to be called (if different) at the front of
your booklet.
Detailed guidance notes to help you complete your My Plan
Section 1: About me
1.1 How to communicate with me:
How do you usually communicate? By speaking
or writing? Can you read and write? Is English
your first language? Do you need an interpreter?
How do you indicate pain, discomfort, thirst and
hunger? How do you like to receive appointment
letters?
1.2 Things you need to know about me and
how I like to be supported:
Include anything you feel is important and will
help staff understand you and support you. For
example, I have never been in hospital, I prefer
male or female carers, I speak other languages, I
need food and drink to be provided for me. I have
problems with my memory and mobility so rely on
my aids, relative or carer.
1.3 Things that I am interested in, passionate
about or enjoy doing:
Do you like watching TV/sports/listening to radio/
music, reading the newspaper, going for a walk,
having naps, particular foods?
Do you like company or being on your own?
Do you like going on trips, attending a particular
event, visiting art galleries or going to music
concerts?
1.4 Things that frustrate or annoy me:
Think about any of the following which might affect
you:
Individuals ignoring your preferences/wishes, or
individuals speaking to your relatives about your
health condition when you are more than capable
of speaking for yourself.
When you have to second guess information being
given to you.
Do you have any rituals in your home which must
be followed by others to prevent any frustrations?
For example, your faith or religious beliefs.
Do you like talking about your family, animals
(pets), your career, hobbies or sport?
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Improving health and care
n Hertfordshire and west Essex
1.5 What helps most when I’m not feeling
good:
What helps you feel better if you are unhappy,
distressed, feeling unwell? For example,
speaking with a family member, speaking with
someone with similar problems, music.
2016-2021
Do you like prefer company, someone sitting
and talking with you or quiet time alone?
1.6 About me (continued):
An extra blank insert to provide additional
information about you if required.
1.7 A typical day:
Let us know what a typical good or bad day
looks like for you so we can understand what
needs to happen for you to have more good
days and fewer bad days.
1.8 I would like to talk about:
You might have some questions regarding
your health and wellbeing. Note them here so
you remember to ask a health or social care
professional next time you see them.
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About me (additional blank sheets available if required)
1.1 How to
communicate
with me
(for example, English
is not my first
language. I need an
interpreter)
1.2 Things you
need to know
about me and
how I like to be
supported
(for example, I prefer
male or female carers.
I have memory and/or
mobility problems)
Date reviewed
3
About me (additional blank sheets available if required)
1.3 Things I am
interested in,
passionate about
or enjoy doing
(for example, religious
belief, hobbies)
1.4 Things that
frustrate or annoy
me
(for example, if
people didn’t listen
to me or respect my
house rules)
1.5 What helps
most when I’m
not feeling good
(for example,
speaking with a family
member or having
time to myself)
Date reviewed
4
1.6 About me (continued)
(Use this sheet to add more information about you if needed)
Date reviewed
5
1.7 A typical day
A good day looks like
Date reviewed
6
A bad day looks like
1.8 I would like to talk about
Questions or relevant information I want to ask my health or care professional
Date
Question
Response
Date reviewed
7
Detailed guidance notes to help you complete your My Plan
Section 2: My community
2.1 List key people involved in your care:
For example, partner, family relatives,
neighbour, GP, carer, social worker, nurse,
pharmacist.
List all the people who currently support you
with your health or social care needs. Outline
how they help you and their contact number.
For example, do you have help to take your
medication? Are you issued with a pill box?
What systems are currently in place to help
you to remember your medication? Are there
any special requirements which affect your
medicines?
CARE HOME
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2.2 Who relies on you and what support do you
provide for them?
For example, I am the sole carer for my partner who is
in a wheelchair. I wash, feed and dress him/her on my
own.
I have a cat or dog who I feed 3 times a day.
2.3 How should they be supported should you
become unwell and need to go into hospital?
For example, my partner would require respite care
(include details of your preferred place for respite if
you have one).
My daughter/son (include names and contact details if
you can) should be contacted to look after the house.
My neighbour (include name and contact details if you
can) would be very happy to look after the cat and has
my house keys.
MEMORY CAFÉ
HEALTH HUB
My community
2.1 List key people involved in your care like your partner, family relatives,
neighbour, GP, carer, social worker, nurse, pharmacist. For example,
assistance you require to manage your medication.
Name of person/
organisation
How they can help me
Telephone/Email
Date reviewed
9
My community
Do you have anyone who relies on you? For example, family members or
pets?
2.2 Who relies on you and what
is your level of support for
them?
Date reviewed
10
2.3 Any suggestions to support them should
you become unwell and need to go into
hospital?
Detailed guidance notes to help you complete your My Plan
Section 3: My personal goals and action
plan
3.1 My personal goals and action plan:
It might be helpful to think of some goals you
would like to achieve over the next 12 months and
make a plan to help you reach them.
These goals might be about achieving something
new, getting back to what you used to do or simply
maintain what you are currently doing.
We recommend a maximum of 3 personal goals at
any one time. Goals should be specific, realistic
and try to have a timeframe in mind. Keep
persevering towards achieving your goal, people
involved in your care can support you with how to
do this or help you adjust the goal if necessary.
Some examples of goals:
• To stay in my own home
• To be able to get to the toilet on my own during
the day
• To keep doing my own shopping once a week
• To remember more things
• To be able to go upstairs to sleep in my own bed
every night
• To stop falling over
• To reduce my weight over the next 3 months
• To lower my blood sugar to normal levels
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3.1 My personal goals and action plan
Things that are important for me to keep doing or I would like to work
towards, for example, reducing my weight, or being able to stay independent
in my own home.
Date
12
I would like to keep doing / achieve
Support I need to do this
Detailed guidance notes to help you complete your My Plan
Section 4: Crisis planning and advance
care planning
This section helps you know what to do if you
suddenly become unwell or need additional care
and support. It provides you with the knowledge
and skills to manage your health and wellbeing
needs, or directs you to your health or social care
professional for advice and support if required.
Advance care planning is also included in case you
are considering this as part of your future planning,
as part of retirement planning or you have been
diagnosed with a serious condition, as this can
help to ensure any wishes you may have are
known. For example, this may include expressing
where you wish to receive your treatment and/or
care, any treatment you may not want to receive
and your wishes around where you would prefer to
die, if your health was getting worse or you were to
be nearing the end of your life.
We understand it may be difficult to think about
your future in this way but doing so better ensures
your wishes can be respected.
We recommend you talk to your health or care
professional to identify ways you can manage your
health and wellbeing if your condition worsens and
to ensure professionals are aware of any advance
care planning wishes you may have.
4.1 In case of emergency contact: Please add
details of your next of kin. This may be a close
relative (partner, children or parent) or a close
friend.
4.2 My community: List the people you give
permission for professionals to discuss your health
and care with, for example, your partner.
4.3 My health conditions: List any health
conditions you have been diagnosed with.
4.4 My allergies and reactions: List any known
allergies and your reaction, for examples, a rash or
diarrhoea. These reactions may be mild or severe.
4.5 My medication: Attach the latest copy of your
repeat prescription. If you do not have a copy,
your usual community pharmacy will be able to
provide you with your latest list of medication.
4.6 If my condition becomes worse I need to:
Talk to your health or care professional about how
you can manage your health and wellbeing if your
health worsens.
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Detailed guidance notes to help you complete your My Plan
Section 4: Crisis planning and advance
care planning (continued)
Putting affairs in order
4.7 Paperwork: It’s a good idea to keep all your
important paperwork in a safe place. We have
listed some of the important documents, which
may be relevant. Let your nominated person know
where the documents are so they can manage
your affairs on your behalf when required.
Organ/tissue removal is carried out with the same
care and respect as any other operation and
does not disfigure the body or change the way it
looks, nor does it delay funeral arrangements. For
information on organ/tissue tissue donation visit
www.organdonation.nhs.uk
Let us know if you have registered for organ or
tissue donation.
4.10 Future wishes
4.8 Making a will: It is a good idea to have a will
to state what you want to happen to your money,
property and assets after you die. Without one, the
law decides what happens, which can be a long
process and a distressing time for your surviving
family. For information on will making visit
www.gov.uk/make-will
In the event of being unable to make decisions for
yourself, you are advised to consider outlining your
wishes so that these can be respected and carried
out.
Please confirm that you have told a trusted friend
&/or loved one where you keep your will.
4.11 If you have a lasting power of attorney
(LPA) health and welfare and/or property
and finance, an advance decision to refuse
treatment (ADRT), and/or a Do not attempt
cardiopulmonary resuscitation (DNACPR),
please let us know contact details and where any
documentation is kept.
4.9 Organ or tissue donation: Organ donation
saves thousands of lives a year and depending on
your medical history you can help by donating all
or some of your organs; when you die.
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If I could not care for myself or if I was dying,
I would like to be cared for at: Consider home,
care home, hospital or a hospice.
If you do not have any of the above in place, but
would like to or would like further information, refer
to:
• Lasting power of attorney,
www.gov.uk/power-of-attorney
or call 0300 456 000
• Advance decision to refuse treatment (ADRT),
speak to your health professional (nurse, doctor
or GP).
• DNACPR (will be completed by a medical
profession)
Speak to your health professional (nurse, doctor or
GP).
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4.1 Crisis planning and advance care planning: My personal details and
emergency contacts
My name:
My NHS number is:
Phone/email:
Religion:
In case of emergency contact:
Name:
Name:
Relationship to me:
Relationship to me:
Contact details:
Contact details:
Date reviewed
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4.2 My community
List the people you give permission to discuss your health or care with
I give you permission to discuss my condition with the following people:
4.3 My health conditions (your health professional can help you if required)
My health condition (s)
Date reviewed
17
4.4 My allergies
(your health professional can help
you if required)
Allergies
Reaction
(e.g. rash or diarrhoea)
Date reviewed
18
4.5 My medication
(Attach your latest prescription here)
If needed, your usual community
pharmacy should be able to provide
you with a recent copy.
4.6 In a crisis – If my condition becomes worse I need to…
Talk to your health or care professional to find out ways to manage your
health and wellbeing if your health worsens.
Changes / symptoms to be
aware of:
Actions to take:
Date reviewed
19
In a crisis – If my condition becomes worse I need to…
Talk to your health or care professional to find out ways to manage your
health and wellbeing if your health worsens.
Changes / symptoms to be
aware of:
Date reviewed
20
Actions to take:
Putting affairs in order
4.7 Paperwork - It’s a good idea to put the following documents
in a safe place in preparation for any hospital stays or when you
are too ill. Let your nominated person know where the documents
are to enable them to manage your affairs on your behalf.
• Bank account (s)/Credit
cards
• Birth certificate
• Marriage or civil partnership
certificate
• Will
• Insurance policies
• National Insurance number
• Contact details: Executor,
solicitor, GP
• Contact details for family,
friends and colleagues
•
•
•
•
•
Hire purchase agreements
Pension documents
Mortgage details
Tax office address
Details of online accounts/
social media
4.8 Making a will
A will states what you want to happen to your money and property after your death,
including arrangements for dependents or pets. Without a will, the law decides
what happens to your property. Advice on making a will can be found here:
www.gov.uk/make-will/ or www.citizensadvice.org.uk/family/death-and-wills/wills/
Have you made a trusted friend or loved one aware of where to find your will?
No
Yes
4.9 Organ or tissue donation
HEALTH HUB
CARE HOME
Depending
on your medical history,
it may be
possible to donate your organs and/
MEMORY CAFÉ
or tissue for transplantation after death. You can find out more about this at
www.organdonation.nhs.uk or by phoning 0800 432 0559.
No
I have registered for organ and/or tissue donation after my death Yes
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4.10 Crisis planning and advance care planning: Future wishes
If I could not care for myself, I
would like to be looked after at
(Also known as ‘preferred place of care’)
When I am dying, I would like
to be cared for at
(Also known as ‘preferred place of death’)
4.11 Advance care planning: Have you written down your wishes?
Lasting power of attorney, health
and welfare (LPA)
Yes
No
Lasting power of property and
finance (LPA)
Yes
No
Yes
No
Advance decision to refuse treatment
(ADRT)
Do not attempt cardiopulmonary
resuscitation (DNACPR)(completed by Yes
an appropriate health care professional)
Contact details:
Contact details:
Where is it kept?
Where is it kept?
No
Date reviewed
22
https://www.healthierfuture.org.uk/myplan
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