Activity Therapy Note (Partial Hospitalization Program)

Activity Therapy Progress Note (PHP)

Patient: [name]

MRN: [identifier]

Date of Service: [date]

Provider: [name, credentials]

Service: Activity Therapy (PHP) [G0176]

Session Timing: [start time] – [end time] ([total] minutes)

Format: [Group: group name, type, size / Individual: rationale]

Location: [facility] [in-person / telehealth]

Session Focus

Modality: [art / music / movement / drama / mindfulness-based / expressive writing / other]

Clinical Purpose: [therapeutic mechanism and targeted symptom domain] (In 2–4 sentences, link activity to treatment goals such as emotion regulation, distress tolerance, grounding, behavioral activation, or social skills training. Identify symptom domain addressed. Explicitly establish therapeutic, non-recreational intent.)

Session Structure: [brief description of session components]

Patient Status & Observations

Appearance/Behavior: [objective descriptors]

Engagement: [participation level, consistency, need for prompts]

Affect: [observed mood, range, congruence]

Interpersonal: [group dynamics, peer interactions, boundaries]

Insight/Skill Application: [ability to identify triggers, articulate coping, apply skills]

Safety: [SI/HI denied or endorsed; risk indicators; actions if indicated] (Document if assessed or required by policy; otherwise state "Not assessed this session.")

Interventions

Psychoeducation: [concepts taught and relation to treatment goals]

Therapeutic Techniques: [techniques used: modeling, guided practice, reinforcement, redirection, limit-setting, distress tolerance coaching, etc.]

Individualization: [adaptations made for this patient] (Include clinical rationale for mid-session modifications if applicable.)

Patient Response

Objective: [observable behavior changes during/after intervention]

Subjective: [patient's self-report if clinically meaningful] (Use brief quotes with attribution.)

Clinical Significance: [progress, partial response, or barrier relative to targeted goal]

Treatment Plan Linkage & Plan

Linked Goal: [treatment plan goal/objective addressed] (Quote or summarize the specific individualized goal.)

Skill Practiced: [specific skill trained this session]

Progress/Barriers: [evidence observed this session] (If linkage unclear, state that clarification with treatment team is needed.)

Next Steps: [focus for upcoming sessions; between-session practice if assigned; team communication or escalation initiated]

Safety Event / Incident

(Include only if occurred.) [Factual summary: incident description, interventions, consultation/notification, disposition, handoff]

Signature: [electronic signature]

Printed Name/Credentials: [name, credentials]

Date/Time Signed: [date/time]