Adaptive Sports/Physical Activity Session Note (Recreational Therapy)

Date/Time: [Date, start time, duration, total session minutes]

Patient: [Patient identifiers per facility policy]

Provider: [CTRS name and credentials; assistants/students/volunteers if present]

Setting: [Location—gym, pool, community site, trail, court, etc.]

Format: [individual / group] (Note co-treat discipline if applicable)

Primary Purpose: [One-line clinical purpose focused on adaptive sport/physical activity participation]

Subjective

(Document in 2–6 bullets or one brief paragraph. Include a meaningful patient quote only when it clarifies pain, barriers, or goals. If no special precautions apply, note "No additional precautions beyond standard facility/sport safety." If precautions are clinically relevant but unknown, state that session was modified to low-risk activities pending verification.)

• [Patient-reported readiness and interval changes since last session]
• [Activity precautions, contraindications, medical devices, and sport/environment-specific risks for today]
• [Patient's stated goal for today's session]

Objective

(Use objective, clinician-observed language. Do not infer data not obtained. If vitals were clinically indicated but not obtained, document why and what compensatory monitoring was used.)

Baseline: [Mobility/transfer baseline; vitals or symptom screen if indicated—HR, BP, SpO2, pain, RPE, fatigue; equipment/skin readiness checks as relevant]

Activities Performed: (Repeat for each activity; include progression/regression vs prior session)

• [Activity name and purpose]

  [Dose: time, distance, sets/reps, intervals, rest breaks, resistance]

  [Intensity: RPE primary; HR zone or talk test if available]

  [Progression/regression compared to prior sessions]

  [Skilled techniques: task analysis, adaptive skill instruction, safety training, cueing, equipment fitting/training, energy conservation, behavioral coaching]

Equipment/Adaptations: [Primary equipment, key configuration settings, adaptive modifications, safety equipment; fit/function issues and actions taken; explicitly label unknowns]

Transfers/Mobility: [Surfaces, technique, devices, assistance level per facility scale, spotting/guarding] (If no transfers: "Remained in [device] throughout session")

Response/Tolerance: [Rest breaks required and rationale; pain before/during/after with location; exertional response; neuromuscular response—spasticity, coordination, balance, dizziness] (Any adverse event or near-miss requires explicit documentation: what happened, contributing factors, immediate response, and follow-up plan—do not omit or minimize.)

Assessment

(Provide clinical synthesis in 1 short paragraph or 4–6 bullets. Link to 1–3 goals from the RT plan of care. Do not assume home carryover or independent safety unless directly observed or tested.)

• [Progress toward RT goals with objective metrics: distance, time, reps, skill accuracy, assist-level changes, rest breaks, cueing required, equipment independence]
• [Clinical impression of tolerance and readiness to progress]
• [Barriers and facilitators impacting participation]
• [Risk assessment for independent/community participation]
• [Need for continued skilled RT services]

Plan

Next Session: [Activity focus; planned progression/regression; equipment needs; staffing/spotting needs]

Carryover: [Frequency, duration, intensity targets with RPE range; technique cues; warm-up/cool-down expectations] (Only include if appropriate and safe for patient)

Safety/Stop Criteria: [Symptoms prompting stop; when to seek medical help; hydration/temperature strategies; pressure relief schedule; fall prevention]

Coordination: [Team updates; caregiver training; community resources; equipment maintenance/reservations]

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Signature: [Provider signature, credentials, date/time signed; co-signature if required by policy]

(For sections not applicable, include a brief clarifying statement—e.g., "No transfers performed"—rather than leaving blank. If objective measures were not feasible, document observable proxies and explain why numeric metrics were not used.)