Aquatic Gait/Balance Training Session Note

Date of Service: [Date]

Patient Name/MRN: [Patient identifier]

Treating Clinician: [Name, credentials, discipline]

Diagnosis/Condition Addressed: [Primary diagnosis/condition]

Timed Code Treatment Minutes: [Integer minutes]

Total Treatment Time: [Integer minutes]

Subjective

[Patient-reported status related to gait, balance, and aquatic tolerance] (2-4 sentences. Include falls or near-falls since last visit with clear attribution, pain or symptoms affecting mobility, fear of falling or water confidence, and any land carryover observations. Use direct quotes when they clarify intent or safety concerns. If subjective unavailable, state reason briefly rather than leaving blank.)

Objective

Aquatic Environment/Safety: [Water depth/immersion level, entry/exit method and assist level, safety equipment used, therapist position]

Vitals: [Relevant vitals if clinically indicated] (Include only for cardiopulmonary history, dizziness, or high exertion. Omit if not indicated.)

Interventions: [Gait and balance activities performed with task type, dose, support/devices, assist level, cueing type/frequency/target, and observed response] (Use standardized assist terms: Ind/Sup/SBA/CGA/min A/mod A/max A. Document cue type as verbal/tactile/visual with frequency and target. Note observable changes in gait symmetry, loss-of-balance events and recovery strategy, or reduced guarding needs.)

Outcome Measures: [Standardized measure name and result] (Only include if formal measure performed.)

Patient Education: [Content taught and method of comprehension confirmation] (Only include if education provided.)

Adverse Events: [Event description, immediate response, follow-up actions] (Only include if adverse event occurred.)

Assessment

[Clinical interpretation] (3-5 sentences. Identify primary gait/balance impairments addressed and most salient observed change. State why the aquatic setting was necessary today. Link findings to fall risk and functional carryover. Note tolerance if it affected dosing. Comment on progress toward goals; if plateau or regression, explain contributing factors and why continued skilled therapy remains appropriate.)

Plan

• [Aquatic progression for next session]
• [Land carryover plan with specific cues and device strategy]
• [Safety and falls-prevention recommendations until next visit]
• [Coordination/communication needs] (Only include if applicable.)
• [Home program updates] (Only include if applicable.)

Signature

Clinician Signature/Credentials: [Signature and credentials]

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