Preliminary Care Coordination Plan Paper
Preliminary Care Coordination Plan Paper
All instructions attached. See RUBRICS scoring guide , shooting for distinguished column please. See proficiency details & instrucions.
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Care Coordination Plan Template
Name:
DOB:
Address:
Payor Source:
Secondary Source:
- Current Problems With Status Summary (Write a brief summary of current and co-morbid illnesses and the reason for care coordination planning.)
- Routine Health Maintenance
Physician:
Physician’s Address:
Physician’s Phone Number:
Preferred Hospital:
General Dentist:
Dentist’s Address:
Dentist’s Phone Number:
Pharmacy:
Pharmacy’s Address:
Pharmacy’ Phone Number:
- Specialty Care
Specialist One:
Discipline:
Physician’s Address:
Physician’s Phone Number:
Treatment Goals:
Specialist Two:
Discipline:
Physician’s Address:
Physician’s Phone Number:
Treatment Goals:
Specialist Three:
Discipline:
Physician’s Address:
Physician’s Phone Number:
Treatment Goals:
Specialist Four:
Discipline:
Physician’s Address:
Physician’s Phone Number:
Treatment Goals:
- Mental Health Provider
Specialist One:
Discipline:
Provider’s Address:
Provider’s Phone Number:
Treatment Goals:
- Hospital Care (List history of hospitalizations.)
Date of Hospitalization:
Hospital Name:
Reason:
Length of Stay:
Discharged to Location:
Date of Hospitalization:
Hospital Name:
Reason:
Length of Stay:
Discharged to Location:
Date of Hospitalization:
Hospital Name:
Reason:
Length of Stay:
Discharged to Location:
- Patient Education (List any educational program or coordination that the patient has completed.)
Name of Program:
When:
Where:
Name of Program:
When:
Where:
Name of Program:
When:
Where:
Name of Program:
When:
Where:
- Rehabilitation Services (List any rehabilitation stays, including in-patient, out-patient, Long Term Acute Care (LTAC), or Skilled Nursing Facility (SNF) stays.)
Name of Rehabilitation Services:
When:
Where:
Length of Stay:
Name of Rehabilitation Services:
When:
Where:
Length of Stay:
Name of Rehabilitation Services:
When:
Where:
Length of Stay:
Name of Rehabilitation Services:
When:
Where:
Length of Stay:
- Medication List (List all medications, dosage, and purpose.)
Medication:
Dosage:
Purpose:
Medication:
Dosage:
Purpose:
Medication:
Dosage:
Purpose:
Medication:
Dosage:
Purpose:
Medication:
Dosage:
Purpose:
- Durable Medical Equipment
Equipment Owned:
Provider:
Equipment Rented:
Provider:
Equipment Ordered:
Provider:
Equipment Needed:
Provider:
Incontinence Equipment:
Provider:
- Home Health Care Infusion Supplies
Enteral Nutrition Provider:
Phone Number:
Parenteral Infusion Provider:
Phone Number:
- Other Services
Social Services:
Transition Services:
Transportation Services:
- Nursing
Skilled Nursing Visits
Name:
Services:
Indication
Treatment Goals:
Hourly Nursing Services
Name:
Services:
Indication:
Treatment Goals:
Respite Care
Name:
Services:
Indication:
Treatment Goals:
Hospice Care
Name:
Services:
Indication:
Treatment Goals:
- Community Services/Referrals
- Cultural Needs
- Signatures
RN Care Coordinator
Patient
Patient Contact Information (e-mail or phone)