Family Meeting Note (Care Planning)

Date/Time: [Start time] – [End time]

Location/Modality: [bedside / conference room / video / phone / other]

Facilitator: [Facilitator name, credentials, and role]

Participants & Decision-Making Authority

Patient Participation: [present / not present] (If not present, briefly state why.)

Capacity/Surrogate Status: [has capacity / lacks capacity / not assessed] (If patient has capacity and others were present, note patient consent to their involvement. If lacks capacity, identify surrogate and basis for authority below.)

• Surrogate: [Name and relationship] – [advance directive / guardianship / statutory next of kin / unclear or disputed] (If unclear, note who will verify and by when.)

Attendees:

• [Name – relationship or discipline – role – decision-making authority if applicable]

Interpreter Services: [Language and interpreter name/ID] (If not needed, state "not needed." If declined, document that it was offered.)

Meeting Purpose & Clinical Context

Reason for Meeting: [Trigger for meeting] (If repeat meeting, note what has changed since prior discussion.)

Clinical Context: [Active conditions, functional trajectory, and prognosis as communicated] (Keep concise; frame decisions without duplicating progress note. If prognosis was not discussed, state "prognosis not discussed.")

Values, Goals & Discussion

Understanding: [Patient/family understanding of illness and situation] (Document baseline understanding and misconceptions addressed. Use teach-back style and attribute statements to speakers.)

Values & Goals: [Stated values and priorities] (Document what matters most, acceptable vs. unacceptable states, and near-term vs. longer-term goals. Use brief direct quotes for high-stakes statements. If values are secondhand, document as such.)

Options & Recommendations: [Options presented, tradeoffs, and team recommendation with rationale] (If deferred, specify what information is needed.)

Conflict or Barriers: [not applicable / describe disagreement or feasibility barriers] (Include only if applicable. Use neutral, attributed language. Note resources offered such as ethics, social work, chaplaincy.)

Decisions & Plan

(Clearly distinguish confirmed decisions from items under consideration. Attribute decisions to the decision-maker.)

Care Focus: [disease-directed with limits / time-limited trial / comfort-focused / other]

Code Status/Treatment Limits: [Decision] (If not discussed, state "not addressed this meeting.")

Disposition: [Target discharge setting and contingency plan]

Safety Plan: [Supervision, precautions, emergency instructions] (Include only if relevant.)

Advance Directive/POLST: [Existing status / new forms completed / pending] (Note whether orders were placed.)

Pending Items: [Items under consideration, information needed, responsible person, timeframe] (Omit if none.)

Action Items & Follow-up

• [Task] – [Owner] – [Timeframe] – [Status]

(If no action items, state "Informational meeting; no action items.")

Next Meeting/Communication Plan: [Next discussion date or trigger; family spokesperson if identified; update cadence and modality]

Time (if billing ACP): [Total face-to-face ACP minutes] (Document that discussion was voluntary. Partition ACP time from other billable services if applicable.)

(For any item not discussed, not assessed, or unknown, document explicitly. Never infer code status, surrogate authority, or patient preferences without explicit confirmation.)