PG 1

NURSING CARE COORDINATION PLAN Place Patient Addressogram here

Case Tracking of complex care patient moves [ >2 changes of inpatient location within one admission ]
Start Date and Time
Date
Weekly and whenever transfer ordered
Patient Moves (Track each move)
To reduce and minimize patient moves unless deemed necessary as advised by treating
Limit convenience transfers to 1
team for comprehensive continuous health care their by increasing patient family trust,
confidence and satisfaction and hospital as a whole Discuss with Nursing Supervisor &
ADON if another is suggested
Nursing Intervention No Date From To
 MDT including family on next business day 1
 Nursing Supervisor involved in the transfer process 2
 Case Management input into transitional care After 2 moves needs MDT including family

 Family notified of transfer 3

 ICON notified if necessary 4
 Others-Social worker, patient navigators and administrator involved 5
6
7
Evaluation Yes [ Y ] / No [ N ]
Resolve Yes [ Y ] / No [ N ]
Employee Signature
Employee No

Nursing Operations Documentation of Interventions on Care Plan Template

Nursing Care Plan FV8 X Intervention is indicated for patient or shift and Not Done/Patient Refused
AAH-009-NSG-V.4 At the time the Intervention is Completed during your shift
Review Date: March 2018 NA Intervention Not Applicable/Not Indicated for your shift