Active Rehabilitation Exercise Session Note

Header

Date of Service: [Date]

Patient: [Full name and identifier]

Provider: [Name, credentials]

Setting: [outpatient / inpatient rehab / SNF / home health / other]

Visit #: [Number in episode]

Supervising Clinician: [Name, credentials] (Include only if assistant provided portion of treatment)

Subjective

[Patient-reported status since last visit including symptom intensity/location, functional changes, HEP adherence and barriers, and concerns for today's session. Use direct quotes for new symptoms or safety concerns.] (If subjective report cannot be obtained, state the reason.)

Interventions

(Document each therapeutic exercise and neuromuscular re-education activity. Evidence of skilled care—cueing, modifications, clinical judgment—must be present; do not list exercise names alone.)

Activity & Position	Dosage	Intensity/Loading	Assistance Level	Cueing Provided	Progression/Regression (rationale)	Patient Response
[Exercise or NMR task with body position/context]	[sets × reps or time]	[Load, resistance, surface, task complexity]	[Independent / SBA / CGA / Min A / Mod A / Max A]	[Verbal / tactile / visual; frequency; focus area]	[Progressed / Regressed / Maintained with brief rationale]	[Tolerance, symptom behavior, movement quality]
[Additional activity]	[Dosage]	[Intensity details]	[Assistance level]	[Cueing provided]	[Change vs prior with rationale]	[Response]

(Add rows as needed. Note technique corrections, safety guarding, and real-time adjustments with brief clinical reasoning.)

Functional Carryover

[Functional task practiced (gait, transfers, stairs, ADL/work simulation), assistance level, cueing, and observed performance changes] (Include only if exercises were translated into functional tasks.)

Patient Education / HEP

[Topic taught, method used, and patient's demonstrated understanding via teach-back or return demonstration. HEP additions or modifications with dosage and frequency.] (Include only if provided.)

Assessment

[Narrative (3–6 sentences): overall tolerance and symptom response; why skilled services were required today; progress toward goals with specific observable evidence; clinical rationale for progression decisions; any barriers or safety concerns. Avoid vague terms like "tolerated well."]

Plan

• [Next session focus and planned progressions with rationale]
• [HEP modifications if any]
• [Coordination or communication needed]

(Note if progress report or recertification is due soon.)

Time Summary

Timed Code Treatment Minutes: [Actual skilled intra-service minutes] (Do not round to units; exclude waiting, resting, toileting, or independent activity.)

Total Treatment Time: [Minutes]

Signature: [Provider name, credentials, timestamp]