Interdisciplinary Care Plan Update (Recreational Therapy)

Interdisciplinary Care Plan Update – Recreational Therapy (RT)

(Use this template to document RT contributions following IDT rounds, care conferences, behavioral huddles, quarterly reviews, significant change reviews, or discharge planning meetings. Omit optional sections that are not applicable. Do not include other residents' identifiable information.)

Date/Time of Note: [Date and time of documentation entry]

Date/Time of Conference/Rounds: [Date and time of IDT event, or "Same as above"]

Setting/Program: [SNF / Rehab unit / Inpatient psychiatric / Geropsychiatric / Other]

Event Type: [Weekly IDT rounds / Care conference / Behavior huddle / Quarterly update / Significant change review / Discharge planning meeting / Other]

Author and Credentials: [Name], [CTRS / RT / Activities Professional], [Department/Program]

Resident Participation: [Present / Not present: reason / By phone or video / Representative present]

Attendees by Role: [List disciplines present, e.g., nursing, social work, therapy, provider, dietitian, psychiatry, psychology, activities—do not include names]

Reason for RT Care Plan Update

[Brief narrative of triggering event and purpose of update] (1–4 sentences. State whether this is a routine review, preferences update, precautions change, behavior/cognition change, significant change review, or discharge planning. If triggered by a risk event, reference the team's decision point without duplicating incident report details. If no preferences were reviewed and no RT changes are proposed, state: "No preferences reviewed; no RT changes recommended.")

Resident Preferences & Strengths

(Include this section when goals or interventions are being created or revised, or when engagement problems are being addressed. Otherwise omit this entire section.)

• Preferred interests/meaningful activities: [Activities relevant to RT care planning]
• Preferred format/context: [Group / 1:1 / co-treat]; [time of day]; [noise level]; [indoor / outdoor] (Include only relevant items)
• Communication considerations: [Hearing, vision, language needs; helpful cues or supports]
• Strengths/assets: [Social skills, coping strategies, creativity, other assets]
• Triggers and preferred approaches: [Known triggers and trauma-informed strategies] (Include only if relevant)

RT Problem Updates

(List active RT problems in descending priority: safety, behavioral stability, rehab/discharge participation, psychosocial well-being. Repeat the problem block for each active problem. If no active RT needs, document: "RT consulted; no active RT needs identified at this time. Reassessment indicated if [criteria]." If a problem is unchanged since last review, state: "No changes to [problem]; current plan continues.")

Problem: [Brief problem title]

Current Status: [Recent observations, trends, and participation patterns] (Include timeframe such as "over past week" or "since last conference." State what has improved, remained stable, or worsened.)

Goal: [Single patient-centered desired outcome linked to preferences]

Measurable Objective(s):

• [Objective with observable criteria and timeframe]
• [Additional objective if applicable] (Add or remove bullets as needed)

RT Interventions:

• [Modality and format: group / 1:1 / co-treat; frequency if specified]
• [Adaptations: sensory modifications, structured choices, graded exposure, behavioral supports]
• [Activity content aligned to preferences and therapeutic goals]

Safety Considerations: [Restriction or precaution, mitigation plan, and who was informed] (Include only when risk affects RT participation, e.g., falls precautions during groups, elopement risk during outings, de-escalation preferences, restricted items. Otherwise omit this field.)

Problem: [Brief problem title]

(Repeat problem block as needed or remove if not applicable.)

Team Coordination & Decisions

(Include when decisions were made during the event. Use bullets as a decision log. If no team decisions occurred, omit this section.)

• Decision: [Plan addition / change / trial / discontinuation]; Rationale: [Brief rationale]; Responsible: [Discipline or role]; Timing: [Date or timeframe]; Hand-offs: [Notifications or communications if applicable]
• (Add bullets as needed)

Refusals & Barriers

(Include when there are repeated declinations, a new refusal affecting quality of life or behavior stability, or refusal of recommended safety mitigation. Otherwise omit this section.)

• What was offered: [Activity or intervention]
• Resident response: [Quote or concise summary of stated reason]
• Education provided: [Benefits and alternatives discussed]
• Alternatives offered and outcome: [Options tried and result]
• Next steps: [Plan, e.g., different time, 1:1 approach, consult SW/psych]

Discharge/Transition Considerations

(Include only if discharge planning was discussed. Otherwise omit this section.)

• Anticipated discharge setting: [Setting if known]
• Planned leisure routine after discharge: [Brief plan aligned to preferences]
• Community resources identified: [Senior center, adaptive recreation, peer or faith community, transportation]
• Caregiver training needs: [Skills, equipment, or education needed]
• Barriers to discharge participation: [Barriers and RT mitigation strategies]

Next Review

Planned IDT review: [Date or timeframe]

Triggers for earlier reassessment: [List specific triggers, e.g., new falls, increased agitation, change in isolation status or engagement, new psychiatric symptoms, change in precautions]

Signature

[Clinician name], [Credentials]; [Title/Department]; [Date and time signed]