Page 57 - Rehab Orientation Manual 4 04 19-updated_Neat

INTERDISCIPLINARY COLLABORATION

Members of the home care team are expected to have ongoing communication about the patient’s
plan of care, to ensure goals are achieved and services not duplicated.

COC (Coordination of Care) ENTRIES AT EVALUATION
The following coordination of care are required upon completion of the initial evaluation and can be
documented in one Narrative Note.

1. Patient: This states that the initial evaluation was completed, and the POC and discharge plan was
discussed with and agreed upon by the patient / family. Also includes any recommendations (DME, other
disciplines, etc.);
2. MD: This reflects receipt of verbal orders from MD including time/date, frequency and duration, specific
therapies, DMEs (if applicable) and discharge plan. If MD is unavailable, document in a COC note that you
attempted to contact MD and you left a message with available office staff (indicate name of person you
spoke to) or voicemail. This shows that you made an attempt to contact the MD. Appropriate and timely
follow up is needed to obtain verbal orders.
3. Case Manager: This reflects contact with RN or PT Case Manager describing the POC. Can refer to
MD note for details without rewriting them here
4. Contract Administration: Reflects DME orders done through Parachute, if applicable.

5. Interdisciplinary Communication: Reflects communication with other disciplines.

Example Coordination Note:

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