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Medical Care Plans/ Assessment Forms
Children with special health
care needs, their families, physicians, and community providers
will benefit from having a clear, written medical summary,
emergency treatment plan and plan of care. These components
can be combined or developed separately. When combined the
Medical Summary, Emergency Treatment Plan and Working Care
Plan are the components of a Comprehensive Care Plan. The
medical summaries, emergency treatment and care plans can
be on paper, disk or if possible web-based. There are multiple
purposes of the medical summary/care plans. These include:
- An available source of information for parents to provide
to the medical, educational and other care teams,
- A quick reference with child-specific information in
a medical emergency,
- An action plan that the entire care team, including
the family and patient develop, use to prioritize, assign
tasks, implement and assess care
- From the Center
for Medical Home Improvement | NICHQ
 Care Plan Oversight
Codes
The new care plan oversight codes are intended
to report care plan oversight services of children with
special health care needs and chronic medical conditions
provided by primary care physicians who coordinate the medical
care management with other medical and non-medical service
providers and family. The codes may encompass oversight
of work or school programs the patient may be attending
where therapy is provided.
- 99339 Individual physician supervision
of a patient (patient not present) in home, domiciliary
or rest home (e.g., assisted living facility) requiring
complex and multidisciplinary care modalities involving
regular physician development and/or revision of care
plans, review of subsequent reports of patient status,
review of related laboratory and other studies, communication
(including telephone calls) for purposes of assessment
or care decisions with health care professional(s), family
member(s), surrogate decision maker(s) (e.g., legal guardian)
and/or key caregiver(s) involved in patient's care, integration
of new information into the medical treatment plan and/or
adjustment of medical therapy, within a calendar month;
15-29 minutes.
- 99340 30 minutes or more (Do not report
99339, 99340 for patients under the care of a home health
agency, enrolled in a hospice program or for nursing facility
residents.)
View the
Article on the new codes in AAP News, November 2005.
For more information, contact the AAP Division of Health
Care Finance and Quality Improvement at dhcfqi@aap.org.
Comprehensive Care Plans
Comprehensive Care Plan Packet 
This packet contains information about the essentials
of comprehensive care planning for children with special
health care needs (CSHCN). Three distinct types of documents
present medical information plans, emergency plans,
and working (action) care plans. When combined
appropriately for CSHCN (based upon need), these tools make
up a comprehensive care plan. A few of the care plan examples
offer a combination of the three types of care plans (ie.
an emergency plan and a medical information plan). From
the National Medical Home Learning Collaborative II
Integrated
Services Care Plan 
A comprehensive assessment that includes: demographics,
current problems w/ status, routine health maintenance,
specialty care, medical support services, hospital care,
education, rehab services, pharmacy needs, medical equipment/home
care, community services, and a parent/caregiver signature
page. Developed by the PA Medical Home
Program - EPIC IC.
Medical and Psychosocial Assessments
Child
History Fact Sheet
The "Child History and Fact Sheet" reviews personal
information, caregivers/ providers, environmental information,
financial/ insurance information, community services, home
care services, special issues, etc. Recommended to be kept
in the patient's chart in an easily accessible place. Developed
by The Center for Infants and Children with Special Needs
Medical
Home Assessment Form
A complete assessment tool to be used by the care coordinator/
provider. Los Angeles Medical Home Project for CSHCN
Primary
Care Family Assessment | Effect
of Child's Disability on Family Members Interview
Provides sections for clinical issues and concerns, status
of problems, and questions to ask the family. From
"The Physician's Guide to Caring for Children
with Disabilities and Chronic Conditions" by Robert
E. Nickel, M.D., & Larry W. Desch, M.D.
Medical Summaries
My
Care Plan
A medical summary and list of community/state resources.
Developed by Palmetto Pediatrics.
Care Plan (Parts I and II)
Part I: Medical Overview Part II: Child description including
information on challenges, procedures/surgeries, equipment,
school and family. Developed by Hitchcock
Clinic—Concord Pediatric.
Medical
Summary
A 2-page summary that includes problem list, specialists,
medications, support services, history review of systems
and procedures/hospitalizations. Developed by the
PA Medical Home Program - EPIC IC.
Emergency Care Plans
AAP Emergency Care Plans
Center for Medical Home Improvement
Emergency
Care Plans
Action/Working Care Plans
Center for Medical Home Improvement Action
Care Plans
Medical
Home Family-Centered Health Care Plan
This care plan is for patients and families to take home
after each visit that defines Problem (reason for visit),
Activity/Intervention, Who will follow up, When, Expected
Outcome, and next Follow up. Developed by Nashaway Pediatrics
Medical
Home Project Actionable Care Plan
This care plan includes: Main Concerns, Related Current
Clinical Information (labs, etc.), Current Plans/Intervention,
Person(s) Responsible, and Due Date & Date Completed.
Developed by the PA Medical Home Program -
EPIC IC.
Last Updated
November 1, 2006
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