Case Conference/Supervision Note (Yoga Therapy)

Note Type: [Case Conference Note / Supervision Note]

Date of Conference: [Calendar date]

Time/Duration: [Start–stop time or total duration]

Modality: [in person / phone / video]

Participants: [List each attendee with name, role, and credential; identify case presenter and supervisor of record if applicable]

Client Identifier: [Initials + internal case code or MRN; for external consultation use de-identified case code only] (Avoid full name or DOB in supervision-only documents.)

Consent Basis: [client consent on file for case discussion / disclosure permitted under treatment team operations / de-identified external consultation with minimum necessary information shared]

Reason for Conference

[Trigger for case review and decision or clarification sought] (1–3 sentences. If routine case review, state that and note the focus area.)

Case Snapshot

• Presenting concerns and functional impacts: [Concise summary]
• Current care context: [Setting, session frequency, stage of care]
• Diagnoses (by source): [Referring clinician diagnoses; yoga therapist observations] (Omit if not relevant to case.)
• Safety-relevant medical factors: [e.g., osteoporosis, glaucoma, uncontrolled hypertension, balance risk, pregnancy, cardiopulmonary limits] (For any safety-critical item that is missing, write "Unknown" and flag for follow-up in Updated Plan.)
• Medications affecting practice safety: [e.g., anticoagulants, antihypertensives, sedatives] (Omit if not relevant to case.)
• Client goals: [One to three client-voiced goals]

Case Formulation

[Narrative clinical reasoning linking presentation to selected interventions] (Include maintaining factors: biomechanical, behavioral, psychological, social; protective factors and strengths. Clearly label "Hypothesis" versus "Observed." Include yoga-therapy conceptual frameworks only when clinically relevant and client-endorsed. Note differential considerations requiring medical evaluation or referral. Align with goals and outcome measures when available.)

Risks, Precautions, and Safety

(This section is mandatory.)

• Physical and medical precautions: [Contraindicated or modified practices, balance and fall risk mitigation, home practice safety parameters]
• Mental health and emotional safety: [Trauma-sensitive accommodations, known triggers, grounding strategies] (Omit if not applicable.)
• Scope-of-practice boundaries: [Boundaries, referral indications, any holds on practice pending clarification]
• Adverse events or near-misses: [What happened, contributing factors, immediate response, and changes made] (Include only if an event occurred. For acute concerns, include current risk level with rationale and mitigations.)
• Unknown safety-critical items: [List items explicitly as "Unknown" or "Not assessed"] (Place a hold on relevant practices until clarified and add corresponding tasks to Updated Plan.)

Interventions Reviewed

(Organize by target problem or goal. If interventions were not reviewed, state: "Interventions were not reviewed during this conference; discussion focused on [ethics / scope / coordination / other].")

• [Target problem or goal #1]

  • Intervention category: [asana / pranayama / meditation / relaxation / education / lifestyle support / home practice]
  • Dose: [Frequency, duration, intensity]
  • Modifications and props: [Key modifications]
  • Teaching approach: [Cueing, pacing, supports]
  • Rationale: [Link to formulation]

• [Target problem or goal #2]

  • Intervention category: [asana / pranayama / meditation / relaxation / education / lifestyle support / home practice]
  • Dose: [Frequency, duration, intensity]
  • Modifications and props: [Key modifications]
  • Teaching approach: [Cueing, pacing, supports]
  • Rationale: [Link to formulation]

(Add additional targets as needed.)

Response to Interventions

• Client-reported response: [Benefits and burdens]
• Observed response: [Movement quality, breath pattern, affect tolerance, attention regulation]
• Adherence and barriers: [Home practice adherence, access issues, symptom barriers]
• Outcome indicators: [Measures tracked and trends] (Omit if not applicable.)
• Negative response or adverse effects: [Details and immediate modification made] (Omit if none occurred.)
• Clinical impressions: [Inferred mechanisms tied to observed data] (Clearly label as impressions, not facts.)

Questions for Supervisor or Peers

1. [Decision-point question about what to do next]
2. [Risk or scope-of-practice question]
3. [Additional consultation question] (Add more as needed.)

Feedback Received

(Mandatory for supervision notes. Use objective language such as "Supervisor advised" or "Team consensus.")

• Clinical recommendations: [Recommendation, rationale, resulting action]
• Safety guidance: [Contraindications, referral triggers, supervision level for home practice; resulting actions]
• Scope and ethics guidance: [Boundaries, consent language, documentation practices; resulting actions] (Omit if not discussed.)
• Interprofessional coordination: [Recommendations for coordination; what information will be shared] (Omit if not discussed.)
• Disagreements and resolution: [Options discussed and final decision with rationale] (Omit if none.)

Updated Plan

• Changes by problem or goal: [What is stopped, started, or modified]
• New precautions: [New contraindications or explicit do-not-do items]
• Revised home practice instructions: [Updates with stop rules: stop if chest pain, syncope, severe headache, new neurologic symptoms]
• Referrals or clearances needed: [Type, timeframe, client agreement]
• Coordination tasks: [Providers to contact; information to be shared]
• Safety-critical follow-ups: [Unknown items converted to assigned tasks]
• Follow-up timeframe: [Next supervision review date; next client session if known]

Attestation and Signatures

[Attestation statement, e.g., "This note summarizes supervision discussion; no direct client contact occurred during this conference."]

Author: [Name, credential, signature, date, time]

Supervisor: [Name, credential, signature, date, time] (Include if required by organizational policy or supervisory agreement.)