Interdisciplinary Team Update Note (Art Therapy)

Date/Time: [date and time of note]

Interval Covered: [last 24 hours / since last team rounds / specified interval]

Author: [name, credentials, role]

Contact Type: [Individual / Group / Both / No Contact]

Contact Summary

(Use one bullet per encounter. If there was no contact, state the reason and note "unable to assess" for clinical observations. Label any collateral-sourced information explicitly.)

• [date/time] — [Individual / Group]; [duration]; [intervention type]; [attendance status]; [material restrictions if safety-relevant]; [brief focus]
• (Additional encounters as applicable)

Participation & Functioning

(Include only domains meaningfully observed. Omit domains not assessed rather than writing N/A.)

• Engagement and task behavior: [initiation, attention, persistence, response to structure]
• Affect and regulation: [observable affect, anxiety/agitation level, use of grounding or regulation strategies]
• Communication and interpersonal: [verbal participation, peer interaction in group without identifying others]
• Cognitive/organizational: [planning, sequencing, flexibility, problem-solving as observed]
• Strengths observed: [skills, interests, protective factors demonstrated]
• (Include only when art content or process is clinically meaningful; avoid unnecessary trauma detail)
  • Observed: [factual description of what was created or done]
  • Patient meaning: [patient's stated meaning, quoted or closely paraphrased]
  • Clinician synthesis: [linkage to treatment goals or symptoms; avoid unendorsed interpretation]

Progress Toward Goals

(Connect observations to 1–3 active treatment plan goals. Emphasize functional outcomes over artwork production.)

• Goal: [treatment plan goal]
  Intervention: [art therapy intervention delivered]
  Response: [observable patient response and skills demonstrated]
  Status: [improving / stable / worsening / variable / unable to assess]
  Barriers/Facilitators: [relevant factors affecting progress]
• (Additional goals as needed)

Risk/Safety

(Include this section only when risk concerns are present, escalating, or when inability to assess is clinically relevant. Document facts and patient statements rather than assigning risk levels unless required by your program.)

• Concerns observed/disclosed: [safety-relevant observations or patient statements]
• Interventions in session: [actions taken]
• Notifications: [who notified, when, method]
• Disposition: [status at end of session]

Recommendations

(Bulleted, actionable items for the interdisciplinary team. Include brief rationale for each.)

• [Recommendation] — [rationale]
• [Recommendation] — [rationale]
• Planned next contact: [date/interval and intended focus]

Signature: [name, credentials, role] — [date/time signed]