Complex Care Plan Template

Hi Everyone!

It's a great weekend!

While it is very cold and snowy in Alberta today, it also means time spent playing board games with my family and video calls to our college student!

So to our topic! The complex care plan template. I know that you are all really interested in giving the best care to your patients.

Communication with the multi-discipline team and transition times are KEY opportunities for communication to go wrong and patient errors to occur. Multi-disciplinary team members such as pharmacists, dietitians and specialists would have a hard time communicating with you if the patient could not remember who you are! Additionally if the patient presents to an emergency department or is admitted to hospital they often have a hard time remembering all their medical conditions and medications and who they multi-disciplinary team members are.

INFORMATIONAL CONTINUITY is typically not done well. It is much better than is used to be here in Alberta with information sharing programs such as NETCARE. Netcare is a secure site that that houses all the lab results, diagnostic imaging and now community visits (limited information about a visit to a family physician) for a particular patient in Alberta. However, the family physician is still the keeper of the depth of information about the patient.

There are many ways of preparing documents to assist the patient with informational continuity. Your referral letters, for instance, often contain pertinent information such as past medical history, medications and allergies. This is an example of informational continuity.

There are also many templates for doing complex care plans and some electronic medical record programs (EMR's) will prepare much of the document for you with information you have entered into your EMR.

I have found, over the years of doing complex care plans, that the usefulness of the complex care plan can be defined as what the patient will benefit from it. I would like to see it used for both informational continuity AND a record of what the patient values and the goals they have for their health. I also want my complex care plans to use language that the patient understands.

So I have a gift for you. Attached to this Blog is an example of my complex care plan template.

I have used this complex care plan template hundreds of times and taught it to many many family physicians. As mentioned, it is an example. It is the template I use as it fulfills all the desired outcomes that I hold standard for my patient with regard to informational continuity while providing a useful document for my patient. I like it simple and on a maximum of two pages!

I trust that you find it of value when you are completing complex care plans for your patients.

xx Sarah, the Charting Coach

I would love to help you with your charting problem!

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