FOD 11: Coordinating transitions of care for non-complex pediatric patients

Key Features

• 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).

Assessment Plan

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

CanMEDS milestones

1. ME 2.2 Integrate clinical information to determine the patient’s clinical status and health care needs
2. ME 4.1 Establish plans for ongoing care, follow-up on investigations, response to treatment and/or monitoring for disease progression
3. L 2.1 Apply knowledge of the resources and/or services available in other care settings
4. ME 2.4 Anticipate changes in health status at the time of transition
5. HA 1.1 Facilitate timely access to services and resources in the health and/or social system(s)
6. COM 3.1 Convey information to the patient and/or family regarding the patient’s care needs and treatment plan
7. COM 4.3 Solicit and answer questions from the patient and/or family
8. COL 3.2 Communicate with the accepting physician(s) or health care professional, clarifying issues as needed
9. COL 3.2 Summarize and prioritize patient issues providing rationale for key decisions
10. COL 3.2 Provide anticipatory guidance for ongoing management, such as results of outstanding investigations and/or anticipated events/outcomes