Non-Disorder Specific Medical Care:
Clinical Treatment Summary

 

The following is an example of information that might be included in a clinical treatment summary to be passed on from pediatric to adult care providers.   This concept was developed by the PACER Center.

Section 1:

INFORMATION ABOUT PATIENT
Name Birthdate
Address Phone Number
Medical Insurance Company / Number Telephone Number
 
INFORMATION ABOUT CONDITION
Diagnosis Mode of Inheritance
 
INFORMATION ABOUT CARE PROVIDERS
Primary Care Provider Address/Telephone Number
Medical Records Number (Hospital) Address/Telephone Number
Other Providers Address/Telephone Number

Section 2: Problem List

PROBLEM STATUS
1.  
2.  
3.  

Section 3: Health Status

General Health  
Speech  
Motor  

Section 4: Current Treatment

Dietary Prescription  
Medication/Interventions  
Comments:  

Section 5: Intellectual Functioning

PSYCHOMETRIC EVALUATIONS
Date Age Test Score Comments

SCHOOL HISTORY
Grade Completed: Resources Required:

Section 6: Support System / Level of Independence

Rank    1 = Independent, able to complete task
            2 = Parent support required for activity or task
            3 = Dependent on parents and others for activity or task   

TASK RATING COMMENTS
Provides regular blood levels 1     2     3  
Makes / keeps appointments 1     2     3  
Understands basics of disorder 1     2     3  
Understands basics of treatment 1     2     3  
Is successful with self-management 1     2     3  
Prepares meals
 1     2     3  
Monitors own medications
 1     2     3  
Does food shopping
 1     2     3  
Has drivers license
 1     2     3  
Maintains checking account
 1     2     3