Promoting Excellence : Multi-Disciplinary Order Sheet / Advance Care Plan

Name:
Cardinal Glennon Footprints: Multidisciplinary Order Sheet / Advance Care Plan for the Child with Life Limiting Conditions. Multidisciplinary order sheet/Advance Care Plan For the Child with Complex Medical Conditions

Definition:
These forms are used to record the care plan for children with a life threatening or terminal condition. One is for the child with complex medical conditions that is not imminently dying and the other for a child who is anticipated to die within approximately 6 months.

Category:
Clinical Care Tools - Case Management & Coordination

Source:
SSM Cardinal Glennon Children's Hospital
1465 South Grand Boulevard
St. Louis, MO 63104
www.footprintsatglennon.org

Contact:
Mary Ann Collins, MHA
[email protected]

How the grantee used this instrument:
When a family decides to place their child on the Advance Care Plan (Care Path) a conference is held with key health care professionals. Decisions re: care of the dying child are recorded. This sheet is placed in the child's chart, issued to all appropriate persons, including family members, and any applicable outside agency.

Keywords:
pediatrics, care coordination, protocols, advance care plan, continuity of care, care plan

To use this tool:
You may print and copy this tool for your own use from this site. Please credit source.

References:
Developed specifically for this project by the project team. Copyright © 2001 Footprints at SSM Cardinal Glennon Children's Hospital. All rights reserved.

To view this tool:
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PDF 79 KB / 4 pages

Posted June 30, 2003

SSM Cardinal Glennon Children's Hospital overview page