FOD 11: Coordinating transitions of care for non-complex pediatric patients
- This EPA focuses on transferring patients from one hospital setting to another or to other health care facilities, and discharging patients.
- This includes summarizing the hospital course and any remaining issues, coordinating ongoing care/follow-up and providing all needed documentation (e.g., summary, prescription) in a timely manner.
- This also includes oral or written transfer of information and responsibility of patient care from one practitioner to another.
- This EPA does not include complex patients (Core).
Direct observation and/or case review by supervisor, subspecialty resident, senior resident, nurse practitioner or other with expertise in transitions
Use form 1. Form collects information about:
- Transition type: transfer; discharge
Collect 4 observations of achievement
- At least 1 of each transition type
- At least 2 different observers
- ME 2.2 Integrate clinical information to determine the patient’s clinical status and health care needs
- ME 4.1 Establish plans for ongoing care, follow-up on investigations, response to treatment and/or monitoring for disease progression
- L 2.1 Apply knowledge of the resources and/or services available in other care settings
- ME 2.4 Anticipate changes in health status at the time of transition
- HA 1.1 Facilitate timely access to services and resources in the health and/or social system(s)
- COM 3.1 Convey information to the patient and/or family regarding the patient’s care needs and treatment plan
- COM 4.3 Solicit and answer questions from the patient and/or family
- COL 3.2 Communicate with the accepting physician(s) or health care professional, clarifying issues as needed
- COL 3.2 Summarize and prioritize patient issues providing rationale for key decisions
- COL 3.2 Provide anticipatory guidance for ongoing management, such as results of outstanding investigations and/or anticipated events/outcomes