Interdisciplinary Care Plan Drafter

Converts goals-of-care assessments and clinical data into a structured, CMS CoP–compliant Interdisciplinary Care Plan (ICP) for hospice and palliative care patients. Covers every required element from patient goals and advance directive status through comfort care plan, IDT assignments, and family conference documentation, producing a DRAFT for licensed clinician and IDT review.

Before You Start

This skill produces DRAFT documentation only. All content requires review by a licensed attending physician or APRN and sign-off by the full IDT before:

• Any care is delivered based on the plan
• Any content enters the medical record
• Any Medicare or Medicaid hospice benefit billing occurs

Critical safety rules:

• Goals-of-care conversations and prognostic discussions must be conducted by qualified clinicians — this skill documents and structures those conversations; it does not conduct them
• Never include statements that constitute a medical order (e.g., "do not resuscitate" as an order) — document patient/family preference and refer to the POLST/MOLST or physician order workflow
• Prognosis statements are labeled [DRAFT — CLINICAL ASSESSMENT REQUIRED]; the skill does not generate prognoses

PII rule: Collect patient initials and case reference only. Never record full name, date of birth, MRN, address, or insurance number in this conversation.