Tips for Maintaining Care Plans

The following action items can be used to create a practice procedure for creating, updating, and sharing growth/puberty care plans:

• Meet with staff to gather information and ideas about establishing an officewide procedure for creating and maintaining care plans.
• Identify roles and responsibilities for who will be creating the plan, documenting information, and maintaining information in the plan, including specific responsibilities for updating elements of the care plan.
• Develop a visit flow for documentation and maintenance of the care plan that considers the patient and family, physician, staff members, office efficiency, equipment, and backup contingencies.
• Include checks and balances in office procedures to ensure that:
  • The clinician reviews the care plan at each visit.
  • All care plan elements are documented or updated.
  • The care plan is shared with the patient and family at the visit, and is shared with essential team members in a timely manner.
  • The benefits and possible side effects of treatment are communicated to the patient and family.
  • Any identified diagnostics tests have been completed, reviewed, and communicated to the patient and family.
  • If tests are not completed, follow up to identify the reason and document the reason for noncompletion.
• Standardize how and where the care plan is documented and maintained. For example:
  • After visit summary in a paper chart or EMR
  • Care plan as a separate document in paper chart or EMR
  • Other practice documentation