Care coordination

A care task belongs to a patient and an assigned person. It has a task description, due date, completion date and status. Open identifies work not yet started; in progress shows an active owner; completed records resolution; escalated marks a handoff that needs attention; cancelled records work that should no longer be done. These states help the care team distinguish an unresolved patient action from an encounter that merely has a signed note.

The follow-up workflow validates the acting clinician through the staff-to-user link. It requires a current verified review privilege and active care coordination assignment for the patient. It applies the task order, completion evidence and reviewer close, then confirms the persisted result. Care Coordinator should keep ownership visible, while Monitoring Clinician remains responsible for clinical decisions. Task completion is an operational event; it is not a diagnosis or emergency clearance.

• Assign. Care Coordinator records the patient, task, responsible person and due date.
• Work. Monitoring Clinician records progress and the actual completion date.
• Escalate. Clinical Reviewer checks tasks that cannot be closed within the agreed path.

Define which follow-up actions belong in a care task and who may assign them. Agree due-date expectations, escalation owners and evidence required to mark a task complete. The access purpose in the care team assignment should cover coordination work for this patient. The clinician’s review privilege must be current on the action date. Check these two records before piloting a task, so an assignment in the roster does not silently substitute for access authority.

Decide how a task is cancelled when the clinical plan changes, and how the team avoids losing an escalated task in an ordinary open queue. Use a patient with an encounter awaiting review, one task due soon and one escalated task. Have the care coordinator and clinician explain who can act next from the recorded task state and assignee. The reviewer should be able to identify the completion evidence and the person who closed it.

A remote reading prompts a clinician to request a patient follow-up. Care Coordinator creates the task for the assigned clinician with a due date. The clinician contacts the patient and moves the task into progress. If the action is completed, the completion date is recorded and the reviewer closes it. If a response is still needed, the task is escalated and remains visible. The related encounter is completed only after the outstanding care task is resolved under the agreed procedure.

• Open care tasks — Track open, in-progress and escalated follow-up.
• Active care assignments — Check who holds current access for the patient and purpose.

Read reading to follow-up and consent to encounter. Rehearse denied access using roles.