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CONTINUITY OF CARE PLANNING FRAMEWORK FOR QUEENSLAND
The General Practice Advisory Council has
developed this Continuity of Care Framework
to guide recommended practice for all service
providers involved
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How to fill out continuity of care planning

How to fill out continuity of care planning:
01
Start by gathering all relevant patient information, including medical history, current medication list, and any recent test results.
02
Review the patient's current condition and identify any ongoing or recurring health issues that require specific care or monitoring.
03
Coordinate with other healthcare providers involved in the patient's care to ensure a cohesive plan that addresses all aspects of their health.
04
Document the patient's goals and preferences for their care, taking into consideration their individual needs and values.
05
Develop a detailed care plan that includes specific interventions, treatments, and follow-up appointments.
06
Clearly communicate the care plan to the patient and their family members, ensuring they understand the steps involved and any recommended lifestyle changes.
07
Regularly review and update the care plan as the patient's condition changes or new information becomes available.
Who needs continuity of care planning:
01
Patients with chronic conditions or complex health needs who require ongoing care and coordination between multiple healthcare providers.
02
Individuals transitioning between different healthcare settings, such as hospitals, rehabilitation facilities, or home care.
03
Older adults who may have multiple comorbidities and require integrated care management.
04
Patients with mental health conditions who benefit from consistent and coordinated support from mental health professionals.
05
Individuals with disabilities who require long-term care and support services.
06
Patients at risk for readmission to the hospital, such as those with heart failure or pneumonia.
07
Pregnant women receiving prenatal care to ensure a seamless transition from pregnancy to postpartum care.
Note: It is important to consult with healthcare professionals or resources specific to your healthcare system for accurate and detailed guidelines on filling out continuity of care planning forms or documents.
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What is continuity of care planning?
Continuity of care planning is a process that ensures seamless and coordinated healthcare services for patients as they transition between different healthcare providers or settings.
Who is required to file continuity of care planning?
Healthcare providers, facilities, and organizations involved in the care of a patient are required to file continuity of care planning.
How to fill out continuity of care planning?
Continuity of care planning can be filled out by documenting patient information, care plans, medication lists, treatment goals, and coordination between healthcare providers.
What is the purpose of continuity of care planning?
The purpose of continuity of care planning is to ensure safe and effective care transitions, reduce medical errors, improve patient outcomes, and enhance patient satisfaction.
What information must be reported on continuity of care planning?
Information such as patient demographics, medical history, current health status, care team contact information, treatment plans, medication reconciliation, and follow-up care instructions must be reported on continuity of care planning.
How do I complete continuity of care planning online?
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