Treatment Plan, Cost Estimate & Informed Consent Discussion Note

Date/Time: [date and time]
Patient: [name, DOB or MRN]
Provider: [name and credentials]
Setting: [clinic / hospital / telehealth / pre-op area]
Participants: [patient present; others present with permission; interpreter if used]

Clinical Decision Context

[Clinical question and urgency] (State the specific decision point and why it is being addressed now. Do not reproduce full HPI or exam.)

[Key patient-specific factors impacting options] (Include only factors that materially affect available options such as comorbidities, contraindications, prior treatment responses, or significant uncertainties.)

• [Problem/Diagnosis 1: current status]
• [Problem/Diagnosis 2: current status] (Include only problems relevant to today's decision.)

Options Discussed

(Document only options actually discussed. Always include a no-treatment or deferral option.)

Option 1: [name of option] — [recommended / reasonable alternative / not recommended]
[Brief description of what this option entails.]
Benefits: [intended outcomes]
Risks/burdens: [material risks, recovery considerations]
Timeline: [key steps and approximate timing]
Cost: [estimate provided / Good Faith Estimate provided / pending / not applicable]

Option 2: [name of alternative] — [recommended / reasonable alternative / not recommended]
[Brief description.]
Benefits: [intended outcomes]
Risks/burdens: [material risks, recovery considerations]
Timeline: [timing]
Cost: [estimate provided / Good Faith Estimate provided / pending / not applicable]

Option 3: No treatment / deferral / watchful waiting
[What happens without intervention.]
Risks of delay: [material risks of non-intervention or postponement]
Monitoring if deferring: [follow-up interval and triggers for action]

Patient Preferences & Decision

Patient goals/values: [stated priorities relevant to decision such as symptom relief, recovery time, function, cost, risk tolerance]

Decision: Patient accepted [option(s)]. Patient declined [option(s)]. (Clearly state what was accepted and declined.)

Reason for decline: [patient-stated reason]; consequences of declining were discussed. (Include only if option declined.)

If decision deferred: [information needed]; [anticipated decision timeframe]; [safety-net instructions]. (Include only if decision not finalized.)

Teach-back: [patient's explanation demonstrating understanding] (Include only if teach-back was performed.)

Plan

• [Problem] — [action and responsible party] ; [timeline]
• [Orders/referrals as applicable with urgency]
• [Pre-procedure preparation or instructions if applicable]
• [Safety net: red flags, who to contact, interim management]
• [Follow-up: visit type, timing, contingencies]

Documentation

• Consent: [obtained / deferred / declined] ; [consent type] ; [form location or e-consent ID]
• Capacity/surrogate: [patient demonstrates capacity / surrogate: name and relationship] (Include only if surrogate involved or capacity assessed.)
• Cost disclosure: [verbal estimate / written estimate / Good Faith Estimate] ; [storage location] (Include only if cost discussed.)
• Other forms: [ABN / out-of-network notice / prior auth status] (Include only if applicable.)
• Pending items: [document or authorization pending] ; [expected timing] (Include only if items outstanding.)