What is it?
The My Health and Me document is designed to contain all significant health related information about a person with Learning Disabilities. People will reside in Bedford, Central Bedfordshire or Luton and have a Bedfordshire registered GP.
What is its purpose?
To keep an accurate and up to date record of an individual’s health needs, including a plan of any action that needs to be taken in order to keep that person fit and well.
It provides personalised information about how someone is when well and at their baseline and further information about how they may present when they are unwell.
It includes key information on their communication, mental capacity and shared decision making.
It enables you to carry out your legal duty to provide reasonable adjustments and help to reduce health inequalities as well as having an important role in maintaining people’s safety.
Please also refer to clinical records including the Reasonable adjustment digital flag, Summary Care record, and the NHS Spine.
Who should complete it?
- Person with a Learning Disability
- Carer/family member
- Involved health professionals
- GPs as part of Annual Health Check and Health Action Planning (appointment feedback is also required)
What is in it?
The My Health and Me Book comprises of four colour-coded sections:
- About me (Blue)
- Communication (Yellow)
- Physical and Mental Health (Green)
- Health appointments (Pink)
How can I get one?
Contact the Health Equalities Service on the following details:
Email: hfs.-elft@nhs.net Tel: 01234 310589
About Me
This section can be completed by you or the individual’s carer and has the
following:
- Personal details
- GP details
- Important people in my care
Communication
This section will have information on how the individual communicates and communication tools to help you communicate with him/ her. There is also important information for you regarding the Mental Capacity Act and how this should be applied for people with Learning Disabilities.
When you are working with a person with a Learning Disability, you should:
- Use short sentences and simple language.
- Give lots of time and speak slowly.
- Emphasize key words with tone of voice, pictures or signs.
- Where possible, make information visual.
- Check the person has understood what you have said.
Helpful Makaton Signs
Top tips for communicating with a person with a Learning Disability
- Establish how the patient communicates – this would be in their My Health and Me/ Hospital Passport document – also ask their carers/family/contact the Learning Disability Liaison Nurses
- Talk to the patient, not over them. Get down onto their level- bend down, sit at the bedside, avoid hovering over and talking down
- Use clear and simple language. Listen carefully to what the person is saying and observe their response.
- Consider if using a pen and paper would be appropriate. Do you need to speak to their family/carer on the telephone?
Consider word swaps
- Medication – Tablet
- Difficulty/ issue – Problem / something wrong
- Discharge – Going home
- CT / MRI / X-Ray / Ultrasound – Use a machine to look at / take pictures/ photos of
- Pain – Hurt / sore / ouch
- High / low – Too much / Not enough
Physical and Mental Health
- This part of the folder is where information that reflects the physical and mental health needs should be detailed.
- It also includes information on medication, the dose, frequency and any other specific information which supports how this is taken.
- You may be required to complete the relevant parts in these sections for example, if you are Physio and support with the section for mobility.
- You could also offer support to the individual or carer/family about what to write.
- This section is where reasonable adjustments are documented that the individual may require to access health appointments i.e. wheelchair accessible environment or an appointment at a specific time of day.
- This is the part of the folder where these can be documented, either by yourself, or carer/family member.
Health Appointments
This section is where feedback from appointments are documented and actions to be followed up, again either by yourself or carer/family member.