Interdisciplinary Team Plan of Care Note (Palliative Care)

Note Header

Date/Time: [Encounter date and time]
Setting: [inpatient / clinic / home / other]
Note Type: [Initial Consult / Follow-up / Family Meeting / Weekly IDT Review]
Reason for Palliative Involvement: [Brief reason(s), 1-3 items]

IDT Participants

• Disciplines present: [Physician/APP: Name] [RN: Name] [Social Work: Name] [Chaplain: Name] [Other: Name/Role] (Include only those present.)
• Patient participation: [present / sleeping / declined / clinically unable]
• Family/surrogate participants: [Name(s), relationship] (Note if interpreter used and language.)
• Information sources: [patient interview / family / chart review / primary team / outside records]

Patient Snapshot

(For initial consults: provide concise overview in 4–6 bullets. For follow-up notes: list only changes since last palliative note or reference prior note date if unchanged.)

• Serious illness context: [Key diagnoses, disease stage/trajectory, current disease-directed treatments]
• Functional status and trajectory: [Current function with recent change]
• Decision-making context: [Capacity status; surrogate name and relationship if applicable]
• Advance care planning documents: [Advance directive / POLST / other — availability and location]
• Code status: [Full Code / DNR / DNI / AND / Not addressed — plan to clarify: [plan]]

Interval Events

(Include only for follow-up notes. Omit entirely for initial consults.)

• [Key medical events, symptom trajectory changes, psychosocial or spiritual changes, new decisions — ordered by clinical significance]

Goals of Care and Treatment Preferences

(Required whenever goals were discussed or attempted. If patient/surrogate declined discussion, document the decline with reason and plan to revisit. If goals were not addressed, state: "Goals of care not addressed this encounter — [reason]. Plan to address: [plan].")

[Conversation summary: who participated, patient capacity status, patient's understanding of illness, information shared, stated goals and values using patient's own words when possible, current care direction]

• Care direction: [life-prolonging / function-focused / comfort-focused / time-limited trial]
• Resuscitation: [Accept / Decline / Prior order honored / Unknown]
• Intubation/ventilation: [Accept / Decline / Trial period / Unknown]
• ICU transfer: [Accept / Decline / Conditional / Unknown]
• Dialysis: [Accept / Decline / Trial / Not applicable / Unknown]
• Artificial nutrition/hydration: [Accept / Decline / Trial / Not applicable / Unknown]
• Other treatment preferences: [Setting-specific preferences if applicable]

Interdisciplinary Assessment

(Include only domains assessed or relevant to current care needs. Keep each domain to 2–4 bullets with actionable findings.)

Symptoms

• Pain: [0–10 severity]; [characterization if impacts management]; [functional impact]; [tolerance/side effects]
• Dyspnea: [0–10 severity]; [on exertion / at rest]; [functional impact]
• Other symptoms: [Symptom, severity, impact]

Psychological

• [Distress, anxiety, depression assessment; coping style]
• [Current supports; safety screening result if indicated]

Social

• [Caregiver availability and burden]
• [Practical barriers: transportation, finances, housing, communication needs]
• [Discharge feasibility and resource needs]

Spiritual/Existential

• [Spiritual distress screening result; what matters to patient spiritually]
• [Chaplain intervention summary] (Document needs and interventions without recording private disclosures.)

Ethical/Legal

• [Capacity assessment basis if relevant]
• [Surrogate identity, relationship, authority, legal documentation status]
• [Ethical tensions and escalation path if present]

Integrated Problem List and Care Plan

(List problems in order of urgency. Include only disciplines with active interventions for each problem. For stable problems, note status and "continue current plan" with key elements. Repeat block for each active problem.)

Problem [#]: [Problem name] — [Status: 1–2 line current state]

• Goal: [Patient-centered goal aligned to values; measurable when feasible]
• Barriers: [Medical, psychosocial, or system barriers]
• Plan by Discipline:
  • Phys/APP: [Medication changes, diagnostics, prognosis communication, referrals]
  • RN: [Symptom monitoring, education, nonpharmacologic measures, coordination]
  • SW: [Caregiver support, resource navigation, placement/hospice logistics]
  • Chaplain: [Spiritual support interventions, rituals, community linkage]
• Owner and Timeline: [Who will do what by when]
• Outcome Metric: [What will indicate success]

Coordination and Handoffs

• Teams updated: [Primary team, specialists, case management, outpatient clinicians]
• Pending consults/referrals: [Consult type and responsible party]
• Disposition: [Plan and required handoffs; what information transfers to whom]

Education and Understanding

(Include when significant education was provided or major plan changes occurred.)

• [Key education provided]
• [Patient/surrogate understanding via teach-back; agreement level]
• [Unresolved questions and plan to address]

Safety Alerts

(Include only when safety concerns are present. Omit section entirely if none identified.)

• Concern: [suicidal ideation / unsafe home / abuse or neglect / caregiver burnout / high-risk medication]
• Mitigation: [Immediate steps taken]
• Escalation: [Actions and notifications]

Follow-up Plan

• Follow-up interval: [Timeline and responsible discipline]
• Next tasks: [Scheduled meetings, appointments, assessments with dates]
• Contingency instructions: [Who to call for symptom crisis; when to seek urgent care]

(Do not infer code status, goals of care, or treatment preferences—these must come from patient/surrogate or verified prior documentation. Always explicitly document code status, surrogate decision maker, and whether goals-of-care discussion occurred. For pain and dyspnea, always include numeric severity when those symptoms are relevant.)