Interdisciplinary Care Plan Update Note (Nursing)

Date/Time: [system timestamp]

Author: [name, credentials, unit/service]

Since Last Review: [date/time of last interdisciplinary rounds or care plan review]

Encounter Context: Hospital Day [#]; Level of Care [current level]; Isolation [type if relevant to coordination]

Current Plan & Nursing Update

[Concise interdisciplinary plan alignment and interval nursing update] (One brief paragraph summarizing alignment across teams and nursing care plan progress since last review. Avoid re-copying stable flowsheet data or full assessments.)

• Primary problems driving stay: [3–6 problem labels]
• Interdisciplinary goals (next 24–48h): [specific, observable endpoints]
• Proposed disposition: [destination / TBD] — EDD: [date / TBD] (Label uncertainty explicitly; do not speculate.)
• Patient-stated priorities: [brief summary or quote if relevant to plan]

Active nursing problems requiring update: (Problem-oriented format. Include only problems with meaningful change or impact on discharge readiness.)

• [Problem/Focus]: [label] — Goal: [target outcome] — Status: [improved / stable / worsened / not yet assessed] with [brief objective indicators] — Interventions & response: [key interventions and patient response] — Plan: [continue / modify / escalate with specific next steps]

(Repeat problem entry as needed for additional active problems.)

Barriers to Discharge

(Always include this section. If none, state: "No barriers identified at this time.")

• Barrier: [what is blocking discharge] — Type: [medical stability / functional / cognitive-behavioral / psychosocial / caregiver / equipment / placement / insurance-authorization / transport / pending tests] — Action taken: [steps completed since last review] — Owner: [role and name if helpful] — Status: [pending / in progress / completed] with expected resolution [timeframe / TBD] — Escalation: [not needed / needed to whom / completed]

(Add additional barrier entries as needed.)

New or escalating risks: [trigger/observation] — Actions: [what was done] — Notified: [role(s) and time] (Include only if present; omit if none.)

Care Coordination

(Document interdisciplinary coordination as proof of communication. Include rounds participation, provider notifications, CM/SW coordination, family updates, and consults only when they impact the care plan or discharge readiness.)

• [Coordination action] — [date/time or message reference] — [recipient and role] — [content summary] — [outcome/response or status]

(Repeat entry for each coordination action. For education, include only if incomplete training constitutes a barrier—note topic, teach-back result, and outstanding needs.)

Plan (Next 24 Hours)

(3–6 concrete next actions tied to barriers, risks, or goals.)

• [Action] — Owner: [role] — When: [timeframe] — [follow-up trigger or contingency if applicable]
• [Action] — Owner: [role] — When: [timeframe]
• [Action] — Owner: [role] — When: [timeframe]

(Use explicit status terms: TBD, Unknown, Pending, Not yet assessed. If disposition is unclear, state "Disposition: TBD; awaiting [specific dependency]." Chart only what was done, observed, or communicated.)