Animal-Assisted Therapy Progress Note (SOAP)

Date/Time of Service: [Date and time]

Clinician: [Name, credentials]

Setting/Service Model: [Location]; [individual / group / family / caregiver-training]

Session #: [Number within episode of care]

Therapy Animal: [Species]; [Program ID]; [Handler role]

AAT Safety Confirmation

• Consent/Assent: [confirmed / issue noted: brief description] (Include guardian consent status when applicable.)
• Contraindication Screen: [cleared / concern: brief description] (If concern present, specify issue and risk controls.)
• Precautions Used: [hand hygiene / barriers / positioning / distance rules / other] (List those applied this session.)
• Animal Welfare: [animal calm and ready / stress observed with modification noted]
• Animal Not Utilized: [Reason]; [alternative approach used] (Only include if animal was not involved this session.)

Subjective

[Patient-reported symptoms or concerns; response to AAT; functional changes since last session; caregiver report if obtained] (Use concise sentences or bullets. Include brief direct quotes only when clinically meaningful. If patient cannot self-report, note the limitation and indicate reliance on observational data in Objective.)

Objective

• Measurable Data: [Relevant metrics: distance, duration, repetitions, assistance level, cues required, behavioral counts, standardized scores] (Include only data tied to session goals.)
• Interventions & AAT Integration:
  • [Intervention/Goal]: [Goal addressed]; [therapeutic task performed]; [how the animal was incorporated]; [skilled clinician actions: grading, cueing, safety management, clinical decisions]; [patient response with objective measures] (Repeat for each major intervention.)
• AAT Dose: [Duration of animal-involved activity]; [number of trials]; [breaks provided]
• Animal Behavior: [Demeanor]; [safety measures or handler actions if any]

Assessment

[Progress toward addressed goals compared to baseline or prior sessions, citing objective data]; [clinical rationale for AAT and how it supported engagement or skill acquisition]; [why continued skilled intervention is needed]; [barriers and planned modifications if progress limited or regression noted]

Plan

• [Next session focus and specific goals to target]
• [Planned AAT use and progression / AAT to be held with rationale]
• [Home program or carryover instructions] (Only include if assigned.)
• [Safety plan updates] (Only include if changes indicated.)
• [Coordination or communication actions] (Only include if applicable.)

Billing & Signature

Treatment Time: [Total minutes]; [timed-code breakdown if required] (If time not captured, note per organizational workflow.)

Clinician Signature/Credentials: [Name, credentials, date signed]

Supervising Clinician: [Name, credentials] (Only include if applicable.)

(Documentation guidance: Every intervention must link to an active treatment goal. Document skilled clinician actions, not just activities. Prefer measurable data over narrative. Describe the animal's therapeutic role without attributing outcomes to the animal unless supported by patient report or objective measure. Omit inapplicable fields rather than adding filler.)