How to Write a Clinical Management Plan

Step-by-Step Guide

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   Step 1: Obtain a clinical management plan form or template from the healthcare institution where you work.

   This is a pre-printed form that allows for an efficient manner of recording and presenting information.
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   Step 2: Collect all of the patient's information from the patient's file.

   This includes personal information such as legal name, patient ID, and age, as well as information about her medical condition and treatment so far. ,, This can be another physician, a nurse, hospice, or other healthcare provider. , For example, if the patient suffers from eczema, the objective of the treatment is probably to minimize itching and skin lesions, while if the patient has terminal cancer, the treatment is most likely palliative to manage pain and maintain as much quality of life as possible. , Be as detailed as possible by describing what preparation to use, what the dosage is, and what indications the medication will treat. , This can include dietary instructions, allergy warnings, physiotherapy or psychotherapy instructions, or instructions that pertain specifically to this patient's personal situation. ,, For example, if a hospice is to monitor the patient's progress in daily reports and review once a week, write this down. ,,
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   Step 3: Write the patient's personal information in the left top corner of the form.

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   Step 4: Record the name and title of the independent prescriber

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   Step 5: that is the physician who initiated treatment

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   Step 6: as well as the name and title of the supplementary prescriber.

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   Step 7: Describe the condition that's being treated and the objective of the treatment.

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   Step 8: Write down which medication or medications are being prescribed

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   Step 9: if any.

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    Step 10: Record any other guidelines or protocols that support the clinical management plan.

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    Step 11: Add instructions on how adaptations to the clinical management plan will be reported

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    Step 12: as well as how both the independent and supplementary prescribers will access the patient's records.

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    Step 13: Include instructions about how the clinical management plan will be monitored and reviewed

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    Step 14: and by whom.

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    Step 15: Include the date upon which the plan was agreed to by the prescriber or prescribers and the patient or primary care provider.

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    Step 16: Leave room for both the independent and supplementary prescribers to sign the clinical management plan.

Detailed Guide

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