Client Oriented Care Record & Action Plan

Home care patients involved in the DIVERT-CARE Intervention receive a personal health record to support flow of information between transitions in care. The personal care record includes relevant clinical information and a patient-centred chronic disease management plan. The record is portable and is taken by the patient as he/she interacts with healthcare providers at different points in the healthcare system.

 

Resources



View other components of the DIVERT Cardio-Respiratory Model

Team Case Rounds

SBAR Communication

Vaccines

Advance Care Planning

Medication Review

Helpline

15 Week Symptom Management