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Organizes pediatric patient information, educational details, and identified challenges into structured sections. Captures current plans such as IFSP, IEP, 504, and IHP, along with equipment needs, special clinical accommodations, and current services. Includes chronic condition management with diagnosis and ICD-10 coding, treatment goals and action items with follow-up dates, behavioral and social goals, and supports for educational, financial, medications, allergies, and recent laboratory results.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/utah-pediatric-shared-plan-of-care-template-care-coordination-information-checklist/357347/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/utah-pediatric-shared-plan-of-care-template-care-coordination-information-checklist/357347.png","ImageObject",442,249,{"name":88,"@type":89},"Maya Linwood","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-17","2026-09-23",true,{"@type":98,"interactionType":99,"userInteractionCount":8},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"What does the Utah Pediatric Shared Plan of Care template capture?","Question",{"text":108,"@type":109},"It captures patient and educational information, challenges, equipment needs, special clinical accommodations, current services, and current plans such as IFSP, IEP, 504, and IHP.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How is chronic condition information recorded?",{"text":113,"@type":109},"It includes a problem list with diagnosis entries and corresponding ICD-10 codes for primary and secondary diagnoses.",{"name":115,"@type":106,"acceptedAnswer":116},"What sections are included for treatment and follow-up?",{"text":117,"@type":109},"The template provides treatment tables for clinical goals/action items, behavioral goals/action items, social/community goals/action items, educational goals/action items, and financial goals/action items, each with dates of last visit, notes needs, responsible specialist/provider, and follow-up dates.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},357347,1791505073,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":8,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":8,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":79},962084928432,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","Utah Pediatric Shared Plan of Care Template To be used with the  \nCare Coordination Information Checklist  \nCompleted by: Click here to enter text. Last updated: Click here to enter text.  \n\n| Patient Information: |  |  |  |\n| --- | --- | --- | --- |\n| Complexity Level: Choose one Insurance: Insurance Policy Chart Number: Number |  |  |  |\n| Patient Name: Click here to enter text.\u003Cbr>Date of Birth: Click here to enter text.\u003Cbr>Parent: Click here to enter text.\u003Cbr>Relationship: Click here to enter text.\u003Cbr>Phone: Click here to enter text. |  |  |  |\n| Educational Information: |  |  |  |\n| School Name: Click here to enter text.\u003Cbr>Grade: Click here to enter text.\u003Cbr>Person of contact: Click here to enter text.\u003Cbr>Phone: Click here to enter text.\u003Cbr>School Information: Click here to enter text. |  | Current Plans:\u003Cbr>☐ IFSP ☐ IEP ☐ 504 ☐ IHP |  |\n| Challenges: | Equipment Needs/Assistive Technologies: |  | Special Clinical Accommodations: |\n| ☐ Behavioral\u003Cbr>☐ Learning\u003Cbr>☐ Physical Anomalies\u003Cbr>☐ Respiratory\u003Cbr>☐ Communication\u003Cbr>☐ Sensory\u003Cbr>☐ Orthopedic/Musculoskeletal\u003Cbr>☐ Feeding/Swallowing\u003Cbr>☐ Hearing/Vision\u003Cbr>☐ Stamina/Fatigue\u003Cbr>☐ Social\u003Cbr>☐ Sleeping ☐ Nutrition ☐ Education\u003Cbr>☐ Other: Click here to enter text. | ☐ Gastronomy ☐ Adaptive Seating ☐ Wheelchair ☐ Orthotics ☐ Stander/Walker ☐ Crutches/Braces\u003Cbr>☐ Feeding Pump\u003Cbr>☐ Tracheostomy ☐ Suction ☐ Nebulizer ☐ Communication Device ☐ Hearing Aids/Cochlear ☐ Monitors:\u003Cbr>☐Apnea ☐O2 ☐Glucose ☐Cardiac\u003Cbr>☐ Other: Click here to enter text. |  | ☐ Room immediately ☐ Dim lighting ☐ Low volume ☐ Sensory toys ☐ Minimize wait ☐ Picture communication ☐ Wheelchair access ☐ Other: Click here to enter text. |\n|  |  |  | Current Services: |\n|  |  |  | ☐ Early Intervention ☐ Transition ☐ SPED\u003Cbr>☐ SLP ☐ PT ☐ OT ☐ APE ☐ PSY\u003Cbr>☐ Home Health |\n\n\n|  |  |  |  |  | ☐ Other: Click here to enter text. |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- |\n| Chronic Condition Management: |  |  |  |  |  |  |  |\n| Problem List: |  |  |  |  |  |  |  |\n| Diagnosis |  |  |  |  |  | ICD-10 Code |  |\n| primary diagnosis. |  |  |  |  |  | ICD 10 code |  |\n| Secondary diagnosis |  |  |  |  |  | ICD 10 code |  |\n| Secondary diagnosis |  |  |  |  |  | ICD 10 code |  |\n| Secondary diagnosis |  |  |  |  |  | ICD 10 code |  |\n| Secondary diagnosis |  |  |  |  |  | ICD 10 code |  |\n| Secondary diagnosis |  |  |  |  |  | ICD 10 code |  |\n| Secondary diagnosis |  |  |  |  |  | ICD 10 code |  |\n| Secondary diagnosis |  |  |  |  |  | ICD 10 code |  |\n| Treatment: |  |  |  |  |  |  |  |\n| Clinical Goals / Action Items |  | Date of Last Visit | Need notes? | Specialist/Care Provider Responsible |  |  | Follow-Up Date |\n| Click here to enter text. |  | Click here to enter text. |  | Click here to enter text. |  |  | Click here to enter text. |\n| Click here to enter text. |  | Click here to enter text. |  | Click here to enter text. |  |  | Click here to enter text. |\n| Click here to enter text. |  | Click here to enter text. |  | Click here to enter text. |  |  | Click here to enter text. |\n| Click here to enter text. |  | Click here to enter text. |  | Click here to enter text. |  |  | Click here to enter text. |\n| Behavioral Goals / Action Items |  | Date of Last Visit | Need notes? | Specialist/Care\u003Cbr>Provider Responsible |  |  | Follow-Up Date |\n| Click here to enter text. |  | Click here to enter text. |  | Click here to enter text. |  |  | Click here to enter text. |\n| Click here to enter text. |  | Click here to enter text. |  | Click here to enter text. |  |  | Click here to enter text. |\n| Social or Community Goals / Action Items |  | Date of Last Visit | Need notes? | Specialist/Care\u003Cbr>Provider Responsible |  |  | Follow-Up Date |\n| Click here to enter text. |  | Click here to enter text. |  | Click here to enter text. |  |  | Click here to enter text. |\n\n\n| Click here to enter text. |  | Click here to enter text. |  |  | Click here to enter text. |  |  | Click here to enter text. |\n| --- | --- | ","cbCaiuozDYt2kLDf","https://ap.wps.com/l/cbCaiuozDYt2kLDf","pdf",950895,"English","# Patient Information\n# Educational Information\n# Challenges and Accommodations\n# Current Services\n# Chronic Condition Management\n## Problem List\n# Treatment\n## Clinical Goals / Action Items\n## Behavioral Goals / Action Items\n## Social or Community Goals / Action Items\n## Educational Goals / Action Items\n## Financial Goals / Action Items\n# Medications, Allergies, and Recent Labs","[{\"question\":\"What does the Utah Pediatric Shared Plan of Care template capture?\",\"answer\":\"It captures patient and educational information, challenges, equipment needs, special clinical accommodations, current services, and current plans such as IFSP, IEP, 504, and IHP.\"},{\"question\":\"How is chronic condition information recorded?\",\"answer\":\"It includes a problem list with diagnosis entries and corresponding ICD-10 codes for primary and secondary diagnoses.\"},{\"question\":\"What sections are included for treatment and follow-up?\",\"answer\":\"The template provides treatment tables for clinical goals/action items, behavioral goals/action items, social/community goals/action items, educational goals/action items, and financial goals/action items, each with dates of last visit, notes needs, responsible specialist/provider, and follow-up dates.\"}]","Utah Pediatric Shared Plan of Care Template - Care Coordination Information Checklist | PDF",1790129692]