Facility:
OUT OF HOME 
CARE HEALTH 
MANAGEMENT PLAN		FAMILY NAME: <PtSurname>          
GIVEN NAMES: <PtFirstName>                   
DOB: <PtDoB>              Sex: <PtSex>
Address:<PtAddress> 
Location/ Ward:
COMPLETE ALL DETAILS OR AFFIX PATIENT LABEL HERE	
Date child or young person entered
out of home care:
	Aboriginal  □     Torres Strait Islander   □ 
Aboriginal & Torres Strait Islander  □  
Neither Aboriginal nor Torres Strait Islander □ 	Cultural / Religious Background:	Preferred Language:  
Interpreter Required: Yes  □  No □
Type:	
This Health Management Plan developed following:
Primary Screen (2a) ☐
Comprehensive Health Assessment (2b) ☐
	Date Primary (2a) Screen
completed:	Comprehensive Assessment (2b)
required: Yes ☐ No ☐	Date Comprehensive Assessment
(2b) completed: Yes ☐ No ☐	
Date this Health Management Plan will be reviewed on:
(Minimum of 6 monthly for children under 5 years and annually for children / young people over 5 years or as clinically indicated)
Within 6 months Review Date:________________________
Within 12 months Review Date:________________________
Other (based on clinical assessment) Review Date(s): __________________________________________________	Out of Home Care Health Management Plan Number:	
ASSESSMENTS THAT INFORM THIS HEALTH MANAGEMENT PLAN                                     (Assessement Conducted by)	
Type of Assessment conducted
(e.g. medical/ physical, developmental, speech, mental health)	Date
conducted	Name
	Designation	Contact details	

					

OUTCOMES FOLLOWING ASSESSMENT AND TARGETED INTERVENTIONS      Health issues requiring follow-up	
Health Issue(s) identified	Actions and Tasks required (eg referral to specialist)
	By whom
(Name, designation contact details)	Timeframe for completion	

				

Additional notes/comments:	

	
Who participated in the development of this Health Plan?
Did the child or young person participate in the development of this Health Management Plan Yes ☐ No ☐
Did the carer participate in the development of this Health Management Plan                           Yes ☐ No ☐
Other Participants:	
Name
	Role	Organisation (if applicable)	

			
HEALTH MANAGEMENT PLAN PREPARED BY:	
Name	Phone	Email
	Designation:	Signature:	Date:	
<DrName>	<DrPhone>				<TodaysDate>