For the purpose of its incentives, when referring to a care plan, FPSC requires documentation of the following core elements in the patient’s chart, as follows:
- There has been a detailed review of the case/chart and of current therapies;
- Name and contact information for substitute decision maker;
- Documentation of eligible condition(s);
- There has been a face-to-face planning visit with the patient, or the patient’s medical representative if appropriate, on the same calendar day that Care Planning Incentive code is billed;
- Specifies a clinical plan for the patient’s care;
- Documentation of patient’s current health status including the use of validated assessment tools when available and appropriate to the condition(s) covered by the care planning incentive;
- Incorporates the patient’s values, beliefs and personal health goals in the creation of the care plan;
- Outlines expected outcomes as a result of this plan, including advance care planning when clinically appropriate;
- Outlines linkages with other allied care providers who would be involved in the patient’s care, and their expected roles;
- Identifies an appropriate time frame for re-evaluation of the plan;
- Provides confirmation that the care plan has been created jointly and shared with the patient and/or the patient’s medical representative and has been communicated verbally or in writing to other involved allied care providers as appropriate. The patient and/or their representative/family should leave the planning process knowing there is a plan for their care and what that plan is.