Complex chronic care coordination

Template

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Medical technologyChoose any

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Counseling

The shared plan of care, including the emergency plan, should go with the child to every visit and emergency evaluation. Recommended continuing the home routines, therapies, and equipment care in the plan. Return precautions given including any change from baseline, fever, feeding intolerance, breathing or secretion changes, more seizures, problems with medical equipment, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with plan. Answered all questions.

Note when inserted as is

Complex chronic care coordination
November 2026: Doing well.
• Active conditions, medications, specialists, equipment, and family priorities reviewed
• At baseline per caregiver
• Growth and nutrition reviewed
• Immunizations and preventive care, including dental care, reviewed
• Medication reconciliation completed
• Shared plan of care updated, including the emergency plan
• Follow up in 3 months

The shared plan of care, including the emergency plan, should go with the child to every visit and emergency evaluation. Recommended continuing the home routines, therapies, and equipment care in the plan. Return precautions given including any change from baseline, fever, feeding intolerance, breathing or secretion changes, more seizures, problems with medical equipment, new symptoms, prolonged symptoms, worsening symptoms, and other concerns. Caregiver expressed understanding and agreement with plan. Answered all questions.

What the sources cover

Month-year and status
Active conditions, medications, specialists, equipment, school, family priorities reviewed
Baseline per caregiver; recent illness; not at baseline
Technology: G-tube, GJ, trach, vent, oxygen, VP shunt, baclofen pump, central line, CIC, wheelchair, AAC
Growth, nutrition, preventive care
Care plan updated with emergency section; medication reconciliation
Home health orders, specialists, school, therapies, nursing hours, forms, social work, respite, development, transition, goals of care, palliative care
Strict return precautions

Return precautions in the template

any change from baselinefeverfeeding intolerancebreathing or secretion changesmore seizuresproblems with medical equipment

Sources

Few formal guidelines cover this topic, so the template also leans on expert opinion.