Aquatic Therapy Daily Treatment Note (PT/OT)

Patient: [full name] | DOB/MRN: [identifier] | Date of Service: [date] | Discipline: [PT / OT]

Treating Clinician(s): [name(s), credentials, and role(s) for all contributors]

Setting: [pool / underwater treadmill / tank; facility identifier] | Total Timed-Code Minutes: [numeric] | Total Treatment Time: [numeric] | Visit: [visit number within POC, e.g., Aquatic visit X/Y]

Subjective

[Today's session focus] [Interval changes since last visit including response to prior aquatic session] [Current pain rating with scale and location] [Relevant participation factors] [Safety screen status]

(Write as a brief paragraph of 3–5 sentences. For safety: if new concerns are triggered, specify them; otherwise state "safety screen: no new concerns." If pain or safety items were not assessed, document "not assessed" with the reason rather than omitting.)

Objective

Water Depth: [waist / chest / shoulder / numeric]

Entry/Exit: [method and assist level]

Therapist Position: [in-water / poolside]

Safety Supports: [devices used, e.g., gait belt, flotation, rails]

Session Format: [1:1 / group]

(Document each skilled aquatic intervention below. Use code-comparable intervention names. Each entry must include dosing parameters and patient response.)

• Intervention: [standardized name] | Minutes: [timed minutes]

  Parameters: [sets/reps, distance, speed, resistance method, buoyancy level as relevant]

  Assist Level: [Independent / Supervision / SBA / CGA / Min / Mod / Max] | Cueing: [type and purpose]

  Equipment: [equipment used or none]

  Skilled Modifications/Progressions: [real-time changes with clinical reasoning]

  Patient Response: [pain behaviors, fatigue, balance losses, compensations, movement quality]

(Repeat intervention bullet for each distinct intervention delivered.)

Post-Treatment Pain: [rating, scale, location] (If not measured, document "not measured.")

Functional Tolerance: [time upright, distance covered, balance tolerance as relevant] (If not measured, document "not measured.")

Adverse Events: [describe if any occurred; otherwise "none"]

Assessment

[Response summary with specific indicators: pain change, distance/time change, assist level change, movement quality] [Progress toward POC goals addressed today with objective indicators] [Skilled aquatic rationale: why aquatic environment was necessary today AND what required skilled clinician involvement] [Limiting factors if present]

(Write 4–6 sentences. Name specific goal(s) addressed. Link clinician skill and aquatic properties to today's specific performance. Do not use "tolerated well" without measurable qualifiers.)

Plan

• [Next session focus with planned progressions or regressions and rationale]
• [Transition-to-land plan if applicable: tasks and criteria for progression]
• [HEP updates if assigned or modified]
• [Safety/risk controls for next visit if relevant]
• [Administrative triggers: progress note due date, reassessment timing]

(Include only applicable items.)

Signature

Treating Clinician: [signature, credentials, date/time]

[Assistant/student participation: components performed and supervision method] (Include only if applicable.)

[Co-signature] (Include only when required by facility policy.)