Interdisciplinary Team Conference Note (Long-Term Care)

Conference Date: [Date]

Start Time / End Time: [Start time] / [End time]

Modality: [in-person / phone / video / hybrid / written input reviewed]

Conference Type: [Admission/baseline care planning / Post-admission comprehensive care plan development / Quarterly/periodic review / Annual review / Significant change in status review / Care conference for specific issue]

Location: [Unit/room or conference room; if remote, note platform]

Resident Name: [Full name]

Identifier: [MRN or DOB per facility standard]

Facility / Unit: [Facility name and unit/wing]

Attending Provider: [Name and role]

Reason for Conference: [One sentence stating why this conference occurred now; if triggered by event or change, include date of event and current status]

Sources Reviewed: [Assessments/notes reviewed, e.g., MDS/RAI, CAAs, therapy evals, behavior logs, weights, wound measurements, falls reports, labs, written input from absent disciplines] (Include only if sources were specifically reviewed; otherwise omit this field.)

Attendance and Participation

Attendees:

• [Name] — [Discipline/Role] — [in-person / phone / video]
• (Add line for each attendee present.)

Expected disciplines not present: [Discipline — reason if known] (Include only if applicable.)

Resident participation: [present / not present]; [engaged / limited by cognition / limited by fatigue / declined]; [communication supports used, if any]

Representative participation: [present / not present]; [Relationship]; [in-person / phone / video]

If resident or representative did not participate: [Reason: not practicable / declined / unreachable]; [Steps taken to facilitate participation with dates] (Required by CMS when participation is not achieved; omit if both participated.)

Resident Goals and Preferences

[Resident-stated goals, desired outcomes, and care preferences shaping plan decisions] (Include brief direct quotes for personal goals, refusals, or discharge wishes. Capture preferences impacting daily care such as routines, meals, activities, risk tolerance, and cultural/spiritual considerations. For shared decision-making, note options discussed and decision reached. For refusals, document alternatives offered.)

Resident preferences not obtainable today due to [reason]; will reassess by [date]. (Include only when preferences cannot be obtained.)

Current Status Summary

[Brief cross-disciplinary snapshot: functional highlights, behavior/mood, nutrition/weight trends, wound or pain status, safety risks] (Use trend language—improved/worsened/stable—anchored to dated facts. Keep concise; omit this section entirely if it would duplicate details in problem discussions below.)

Problem-Oriented Conference Decisions

(Order problems by highest risk first, then resident-priority goals, then quality-of-life priorities.)

[Problem Name]

Current Status: [Brief description with observable data, dates, measurements; attribute secondhand information]

Goal: [Measurable, time-bound goal; for comfort-focused care, state the guiding aim]

Barriers/Risks: [Clinical, operational, or social barriers; autonomy vs. safety tradeoffs] (Include only if relevant.)

Agreed Interventions:

• [Discipline] — [Action]
• (Add line for each discipline with assigned interventions: Nursing, Therapy, Social Services, Dietary, Activities, Provider, Behavioral Health, etc.)

Medication/Treatment Decisions: [start / stop / taper / hold / no changes] — [Details including monitoring plan] (Include only if medication or treatment decisions were discussed. If decision deferred, note needed information and timeframe.)

Safety Decisions: [Fall prevention changes, aspiration precautions, elopement interventions, restraint decisions, environment changes, assist level updates] (Include only when relevant.)

Responsible Party and Timeline:

• [Action] — Responsible: [Name/Role]; Due: [Date]; Follow-up metric: [Measure/target]
• (Add line for each action with single accountable owner.)

Education/Communication: [What was explained to resident/representative, their response, teach-back completed]

(Repeat problem block for each problem discussed.)

Items reviewed with no changes: [List domains] (Optional; include when domains were reviewed without changes.)

Orders, Referrals, and Tasks

(Include this section only if actions were decided.)

Orders to be placed:

• [Order description] — Ordering clinician: [Name/Role]; Expected completion: [Date/Time] (If provider not present, note "Recommendation—pending provider review.")

Referrals:

• [Specialty] — Reason: [Reason] — Urgency: [Urgency] — Responsible: [Name/Role] — Target date: [Date]

Operational tasks:

• [Equipment, training, environmental changes, or family contact tasks] — Responsible: [Name/Role] — Target date: [Date]

Follow-Up Plan

Next Review: [Next interdisciplinary review date or rule]

Triggers for Earlier Review: [Conditions prompting earlier conference: fall with injury, rapid weight loss, new pressure injury, escalating behaviors, hospitalization/return, significant functional decline]

Communication Plan: [If resident or representative was absent: summary to be communicated, who will communicate, and by when] (Omit if both participated.)

Authentication

Author: [Name and role]

Signature: [Electronic signature with date and time]

Reviewed by: [Name/discipline] on [date] (Include if co-signed or reviewed.)

Written input reviewed from: [Discipline] dated [date] (Include if applicable.)