Consult Note (Dance/Movement Therapy)

Date/Time: [Date and time of encounter]

Author: [Author name and credentials, e.g., BC-DMT, R-DMT]

Service/Department: [Service or department name]

Patient Location: [Inpatient unit/room/bed or virtual location]

Encounter Type: [in-person / bedside / telehealth]

Referral Details

• Requesting clinician/team: [Name/role or service]
• Referral source: [order / verbal request / team rounds]
• Referral question(s): [Answerable prompt stating the DMT question(s) to be addressed, e.g., appropriateness for coping support, feasibility of movement intervention given medical constraints, movement-informed assessment focus]
• Clarification: [How the referral question was clarified, or that it could not be clarified and what general screening approach was used] (Include only if referral question required clarification.)
• Information sources and communication considerations: [Chart, nursing/primary team input, caregiver; interpreter use; cognitive/communication limitations; sedation] (Include only if relevant to the assessment.)

Pertinent Medical Context

(Include only information that directly affects DMT participation and safety. Omit this section entirely if the consult was observation-only with no movement engagement and no precautions influenced the assessment.)

• Admitting diagnosis and clinical status: [Only details relevant to DMT safety/tolerance such as pain, fatigue, dizziness, oxygen needs]
• Mobility/activity orders: [Mobility/activity order]; Weight-bearing status: [Status]; Precautions: [Isolation / spine / fall / other]
• Lines/tubes/devices impacting movement: [List only those constraining movement, e.g., oxygen delivery, IVs, drains, monitors]
• Behavioral/safety considerations: [Fall risk, agitation, elopement risk, sitter, other relevant factors] (Include only if applicable.)
• Relevant concurrent consults: [PT / OT / Psychiatry / Palliative Care / other] (Include only if applicable.)

Patient-Reported Concerns and Goals

(Use patient-centered language. Include brief direct quotes only for high-salience statements. Omit this section if not obtained and absence is not clinically relevant; if absence is clinically relevant, state why briefly.)

• Priorities/concerns: [Anxiety / pain / motivation / body image / isolation / mood / sleep / other]
• Movement background and preferences: [Prior movement/dance experience; preferred activities or music; cultural considerations]
• Consent preferences and boundaries: [Touch boundaries; trauma-informed considerations; privacy/modesty preferences] (Include only if applicable.)

Movement-Informed Assessment

(Use plain, interdisciplinary-legible language. Avoid diagnostic conclusions based solely on movement observation. Avoid stigmatizing language and speculative trauma narratives; document only what is disclosed or clinically necessary. Discipline-specific terminology may be included parenthetically but should not replace plain-language descriptions.)

• Encounter context: [Position: bed-level / seated / standing]; [Arousal/alertness]; [Participation level: engaged / guarded / declined / other]
• Safety and tolerance: [Breathlessness / dizziness / pain behaviors / vital sign changes]; [Rest breaks needed]; [Stop conditions used] (If movement was not attempted, state why.)
• Movement observations:
  • Posture, alignment, and breath pattern: [Brief descriptors]
  • Movement initiation, range, coordination, and rhythm: [Brief descriptors]
  • Grounding and balance: [Weight shift / steadiness / support needs]
  • Affect congruence and expression: [Brief descriptors]
  • Relational attunement: [Mirroring / turn-taking / eye contact / proximity]
  • Self-regulation responses: [Orienting/soothing strategies; recovery time; observable regulation changes]
• Brief intervention performed: [Technique: grounding / breath-movement coupling / mirroring / imagery with movement / other]; [Duration and intensity]; [Observable response and/or patient-reported outcome] (If no intervention performed, state "Assessment only" and reason.)

Clinical Impression

[Concise formulation that directly answers the referral question. State whether DMT is indicated / conditionally indicated / not indicated. Identify key facilitators and barriers (e.g., medical tolerance, cognition, motivation, pain). Link salient observations to functional or coping implications using cautious language (e.g., "appears," "may be consistent with"). Flag any risk factors relevant to DMT scope.]

• Facilitators: [List briefly]
• Barriers: [List briefly]

(Facilitators/barriers list is optional; include only if helpful for clarity.)

Recommendations

• DMT involvement: [Indicated / Not indicated / Defer pending: (specify condition)]
• Proposed frequency and duration: [Frequency]; [Session duration]
• Session parameters: [Bed-level / seated / standing / ambulation as tolerated]; [Individual / group]; [Co-treatment with PT/OT if applicable]; [Environment/setup considerations]
• Short-term goals: [Observable, measurable goals] (List 2-3 goals as appropriate.)
• Contraindications/hold parameters: [Specific hold/stop parameters relevant to DMT] (Include only if applicable.)
• Alternatives if DMT not recommended: [Service suggestions or strategies] (Include only if DMT not indicated or limited.)
• Interdisciplinary coordination: [Nursing reinforcement of self-regulation strategies; complementary goals with PT/OT; precautions for team awareness] (Include only if applicable.)
• Patient/caregiver education provided: [Topic(s); method/materials; patient understanding] (Include only if education provided.)
• Notifications: [Who was notified (primary team, RN) and method; note urgency if applicable]

Follow-Up

[Disposition: DMT will follow during admission with anticipated timing / One-time consult with re-consult criteria / Reassessment deferred pending (specific condition or event)]

(Required sections: Referral Details, Movement-Informed Assessment, Clinical Impression, Recommendations, and Follow-Up. If a required section cannot be completed, include a brief statement explaining why. Optional sections—Pertinent Medical Context and Patient-Reported Concerns—may be omitted if empty and not clinically relevant. Maintain minimum-necessary documentation for sensitive mental health content. Use respectful, patient-centered language recognizing that patients may read their notes.)