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

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

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.

Clinical Care Tools - Case Management & Coordination

SSM Cardinal Glennon Children's Hospital
1465 South Grand Boulevard
St. Louis, MO 63104

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.

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.

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:
To view the tool in your browser left-click on the link below or to download to your computer right-click on the link.
pdf PDF 79 KB / 4 pages

Posted June 30, 2003

SSM Cardinal Glennon Children's Hospital overview page

# GLEN5, type:case_management

Promoting Excellence in End-of-Life Care was a national program of the Robert Wood Johnson Foundation dedicated to long-term changes in health care institutions to substantially improve care for dying persons and their families. Visit for more resources.

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