Page 55 - Rehab 2020
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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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