Clinical Transition Plan - Illinois

State of Illinois - Department of Human Services
Clinical Transition Plan
IL462-4000 (N-4-11)
Page 1 of 8
PURPOSE: To Facilitate the continuity of care for an individual transitioning to alternate placement. The
Clinical Transition Plan is intended to supplement the Transition Plan by providing more detailed
information relative to the clinical issues.
COMPLETED BY: Professional Nurses and Primary Care Physicians
GENERAL INFORMATION:
1. The entire form is to be completed by a professional nurse, designated by the Director of Nursing,
and a Primary Care Physician.
2. The original is to be filed in the medical record with a copy retained by the Habitation Plan
Coordinator (HPC) and the designated nurse.
3. When changes to a section occur, the section is to be updated by the designated nurse and/or the
Primary Care Physician with a newly completed page and placed in the Clinical Transition Plan in
the proper order. The HPC and designated nurse will each retain a copy. The old section should
be removed.
4. The Clinical Transition Plan will be reviewed prior to discharge to ensure accuracy. The designated
nurse will be responsible for informing the Primary Care Physician that the plan requires updating.
5. The HPC is responsible for ensuring this document is provided to the potential provider when visits
are scheduled.
PROCEDURE
1. The Clinical Transition Plan will be initiated when an individual's name is placed on Tier 1. This Plan
will be completed prior to the individual visiting a potential community provider.
2. Sections I through IV and Section VI (Nursing) are to be completed by the designated nurse.
3. Section V and Section VI (Physician) are to be completed by the Primary Care Physician.
4. Section VII is to be completed by the designated nurse when the supporting clinical documents are
attached to the Clinical Transition Plan packet.
5. The primary care physician and the designated nurse are to sign and date when their sections are
completed.
INSTRUCTIONS
1. May use (TAB) key to move forward from field to field and (SHIFT) (TAB) to move back from field to
field.
2. May use (ENTER) key to "check" a box.
3. NOTE: If you cannot read all of what you typed in a section (there may be a "+" sign at the end of
the typing), only what you can read will be printed.
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