Healthcare Executed MDT MWC and Booster Base

Healthcare Executed MDT MWC and Booster Base

This executed Multidisciplinary Team (MDT) record documents the Medical Wellness & Care (MWC) plan and Booster Base recommendations reviewed and agreed with the patient. The MDT has evaluated clinical status, risks and benefits of proposed interventions, and data-sharing necessary for coordinated care. Patient Name:    Date of Birth:    Medical Record #:

Patient Information

Female    Male    Non-binary    Prefer not to disclose

Insurance Information

MDT Meeting Details

Meeting Date:    Time:    Location:

Physician    Nurse    Pharmacist    Social Worker    Therapist    Patient Representative

Clinical Summary

Summary of current clinical status and reason for MDT review (brief):

Proposed MWC Plan and Booster Recommendations

The MDT proposes the following medical wellness and care (MWC) interventions and booster vaccinations as clinically indicated. Each recommendation is documented with rationale, expected benefit, and known risks. Proposed MWC components (check all that apply):

Medication management / reconciliation    Home care / nursing services    Physical / occupational therapy    Specialist referrals    Psychosocial support services

Booster Vaccination Recommendations (check and specify recommended administration date):

COVID-19 booster — Recommended date:
Influenza vaccine — Recommended date:
Tdap (tetanus/diphtheria/pertussis) — Recommended date:
Other — describe: Date:

Risks, Benefits, and Alternatives

The MDT has explained the anticipated benefits, material risks, and reasonable alternatives to the recommended MWC interventions and booster vaccinations. The patient has the right to refuse or withdraw consent at any time. By checking the boxes below the patient acknowledges understanding of these statements and that questions were addressed.

I understand the benefits and risks of proposed interventions and boosters.
I understand reasonable alternatives and that I may refuse or withdraw consent.
My questions were answered to my satisfaction.

HIPAA / Information Sharing Authorization

I authorize disclosure of my protected health information among members of the MDT listed above and relevant care entities for the purpose of care coordination, treatment planning, and administration of recommended boosters. This authorization includes immunization records, medication lists, problem lists, and discharge planning information where necessary for the MWC plan.

Medical History

Emergency Contact

Patient Consents and Certifications

By signing below I certify that the information provided is true and complete to the best of my knowledge. I authorize the MDT members to implement the plan described above and to administer recommended boosters unless I revoke consent. I understand I may revoke this authorization in writing, except to the extent actions have already been taken in reliance on it.

I consent to the MDT MWC plan as documented.
I consent to administration of recommended booster vaccinations.
I consent to sharing relevant health information among MDT members for treatment and care coordination.

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