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Coordination of Care

Page history last edited by PBworks 17 years, 3 months ago

Coordination of Care

 

Discussion of FSA instruments appropriate for communication of coordination of care when more than one clinician, provider or organization is involved with patient care concurrently.

 

 

 

 

 

 

Use Case Posting:

 

A patient with cancer is receiving treatment in an Oncology center, a research hospital 1000 miles away, and at home. What FSA instruments or measurements are appropriate or desirable to be used in the CCR/CCD for data exchange?

 

Use Case - Referral Documentation:

A resident in a LTC facility has an appointment to see a specialist in the physician office. A referral form which includes FSA information, current meds, diagnosis, etc. is sent to the specialist. The specialist documents a note from the visit and returns the referral form. The referral has two purposes -- provide the most up to date continuity of care information to the specialist and provides a place for the specialist to document the findings/plan from the visit (the referral/note is filed in the medical record as documentation of the visit). (Submitted by MDougherty)

 

This same LTC resident may also receive dialysis off site and they too would require similar referral documentation and the ability to report back to the LTC facility (jms)

 

Community-based services -- Intake and service coordination:

Community aging agencies serving elderly at risk for depression and chronic illness provide assessment and referrals to community services. (S Sharkey)

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