Animal-Assisted Therapy Discharge Summary

Document type: Animal-Assisted Therapy Discharge Summary

Author name, credentials, discipline: [Author name, credentials, discipline]

Date of authorship: [Date of authorship]

Date of discharge: [Date of discharge]

Patient name: [Patient name]

MRN: [MRN]

DOB: [DOB]

Care setting: [inpatient / outpatient / home health / school-based / residential]

Referring/treating provider: [Referring/treating provider]

Episode Overview

• Reason for Episode Conclusion: [Goals met/maximum benefit achieved / Plateau/lack of measurable progress / Medical change / Transition to different level of care / Patient preference / Non-attendance/administrative discharge / Other] — [Brief clarifying text] (If unplanned, begin with "UNPLANNED DISCHARGE" and specify what information is limited or unavailable.)
• Episode Dates: [Start date] to [End date]
• Service Delivery: [Planned frequency] vs [Actual frequency]; [Total visits completed]; [Format: individual / group / telehealth]
• Referral Indication: [Diagnosis/condition] — [Statement of skilled need at onset]

Animal-Assisted Therapy Context

(Include only if animals were intentionally incorporated into goal-directed treatment. If AAT was planned but did not occur, note the reason in Episode Overview and omit this section.)

• Modality: [Goal-directed Animal-Assisted Therapy / Animal-assisted activity] — [Rationale linking animal involvement to therapeutic targets]
• Screening and Consent: [Consent status]; [Allergy/asthma screening]; [Fears/phobias]; [Cultural considerations]; [Immunocompromised status if applicable]; [Contact or feeding restrictions if any] (Document only what was explicitly assessed; do not infer.)
• Animal/Handler: [Species]; [Program identifier or animal name per policy]; [Handler role]. Animal health clearance and temperament evaluation on file per program requirements.
• Infection Control: [Hand hygiene method and timing]; [Environmental controls]; [Exposure avoidance measures]
• Animal Welfare: [Session modifications due to animal stress cues / No signs of animal stress observed]

Baseline Functional Status

• Functional status: [Relevant domains: mobility, ADLs/IADLs, communication, cognition, affect regulation, participation]
• Assistance level and devices: [Level of assistance]; [Assistive devices/technology]
• Safety-relevant status: [Falls risk]; [Supervision needs]; [Behavioral concerns]
• Standardized Measures: [Measure name] — [Baseline score] ([Date]) (Include only if used; list each measure separately.)

Goals and Attainment

(List each active goal using the structure below. Ensure each goal's attainment status is supported by objective evidence.)

Goal #1

• Goal statement: [Goal statement]
• Baseline status: [Baseline functional performance]
• Target level: [Target outcome criteria]
• Discharge status: [Met / Partially Met / Not Met / Not Assessed]
• Supporting evidence: [Objective measure, assistance level, or observed performance at discharge]
• If not met: [Plateau / Medical issue / Attendance / Barriers / N/A]

Goal #2

• Goal statement: [Goal statement]
• Baseline status: [Baseline functional performance]
• Target level: [Target outcome criteria]
• Discharge status: [Met / Partially Met / Not Met / Not Assessed]
• Supporting evidence: [Objective measure, assistance level, or observed performance at discharge]
• If not met: [Plateau / Medical issue / Attendance / Barriers / N/A]

(Add additional goal blocks as needed.)

Interventions and Response

(Summarize skilled interventions by problem or goal area. Prioritize safety concerns first, then functional impact.)

[Problem/Goal Area 1]

• Skilled methods: [Graded tasks, cueing strategies, environmental modification, caregiver training, other]
• Dose: [Intensity, frequency, duration if meaningful]
• Response: [Key response patterns observed]

[Problem/Goal Area 2]

• Skilled methods: [Methods]
• Dose: [Dose]
• Response: [Response]

(Add additional areas as needed.)

AAT-Specific Interventions: [Description of how animal involvement targeted therapeutic objectives—what the animal added to treatment, not just presence] (e.g., using dog-handling commands to elicit bilateral reach; practicing pragmatic language during structured animal-care routines)

Education and Training: [Patient education topics]; [Caregiver training content and demonstrated competency]; [Written materials provided]

Adverse Events: [No adverse events related to therapy or animal interaction] OR [Event details: what happened, actions taken, notifications made, patient outcome]

Discharge Functional Status

• Functional status: [Relevant domains: mobility, ADLs/IADLs, communication, cognition, affect regulation, participation]
• Assistance level and devices: [Current level of assistance]; [Devices/technology]
• Safety supervision needs: [Current supervision/assistance requirements]
• Standardized Measures: [Measure name] — [Discharge score] ([Date]); Change from baseline: [Improved / No change / Declined] (If not repeated, state "Not assessed" with reason.)

[Summary comparing baseline to discharge status, highlighting clinically meaningful changes, persistent limitations, and current safety/support requirements] (2–3 sentences)

Remaining Deficits and Barriers

• Residual impairments and functional limitations: [List]
• Barriers to further progress: [Medical, cognitive, psychosocial, environmental, adherence factors]
• Tasks still requiring assistance: [Tasks and rationale]
• Limitations due to early/unplanned discharge: [Items not assessed and associated risks] (Include only if applicable.)

Safety Considerations

• Falls risk and supervision: [Risk level]; [Required supervision]
• Cognitive/behavioral safety concerns: [Concerns and mitigation strategies] (State "Not assessed" if applicable.)
• Equipment safety requirements: [Device setup, fit, maintenance, precautions] (State "Not assessed" if applicable.)
• Animal-related safety guidance: [Allergy/asthma triggers]; [Bite/scratch risk mitigation]; [Hygiene expectations]; [Home pet guidance if assessed] (Include only if applicable.)

Discharge Recommendations

Home Program: [Components]; [Frequency/duration]; [Progression rules]; [Stop criteria and when to seek help] (If no home program provided, state reason.)

Caregiver Recommendations: [Cueing, setup, supervision level]; [What to avoid]; [Community resources] (Omit if no caregiver involved.)

AAT-Related Carryover: [Recommendations for continued animal-related engagement or avoidance if contraindicated]; Future AAT should follow program safety processes. (Include only if assessed and appropriate.)

Follow-Up Plan

• Next services and referrals: [Referrals placed]; [Referrals recommended]
• Follow-up timeframe: [Timeframe]; [Responsible party]
• Communication completed: [Referring provider notified]; [Summary sent to recipients]
• Transition of care coordination: [Receiving setting/provider]; [Handoff details] (Include only if transitioning to another level of care.)

Author Attestation

[Author signature], [Credentials] — [Date/time]

(If therapy assistants contributed to care or documentation, indicate supervisory review was completed and clinical judgments were made by the licensed clinician.)

(If any key element is missing or not assessed, explicitly document the limitation and reason.)