CARE COORDINATION PLAN FORM--sample 2025

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Examples of care coordination include developing a plan for how a patients care will be managed, communicating with all of the numerous participants who are caring for a patient, and making sure that patients receive the services they need in a timely manner.
Every care plan should include: Personal details. A discussion around health and well being goals and aspirations. A discussion about information needs. A discussion about self care and support for self care. Any relevant medical information such as test results, summary of diagnosis, medication details and clinical notes.
Focus on client, not your interpretation of the facts. Document the type of contact, if it was face to face, and where the visit was held. Note who was present and their relationship to the client. Make a notation of the date and time.
Here are some important guidelines to consider when making care notes: Care notes should be recorded at the end of every shift. Care notes can be written by hand or typed. Write down events in the order in which they happened. Include both positive and negative occurrences and anything out of the ordinary.
Care coordination involves the deliberate organization of patient care activities between two or more participants (including the patient) involved in a patients care to facilitate the appropriate delivery of health care services. Care coordination is a key component of a patient/family-centered medical home and is

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Good clinical notes should: Clearly outline the patients medical history, current condition, and treatment plan. Be organized in a logical structure, making it easy to understand. Include objective data, such as vital signs and lab results, alongside subjective information, like patient complaints and observations.
Examples of specific care coordination activities include: Establishing accountability and agreeing on responsibility. Communicating/sharing knowledge. Helping with transitions of care.

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