Aquatic Therapy Group Session Note

Date of Service: [Date of service]

Session Time: [Start time - End time] | Total Treatment Minutes: [Billable skilled minutes]

Clinician: [Clinician name and credentials]

Visit Type: Aquatic Therapy – Group Session

Diagnosis/Problem Addressed: [Primary diagnosis/problem(s) addressed today]

Group Size: [Number of participants] (Required; do not include names or identifiers of other participants.)

Therapist Attendance: [Constant / intermittent] attendance provided throughout session

Group Format/Focus: [Brief description of session structure and therapeutic focus]

Subjective

[Patient-reported symptoms, changes since last visit, functional status, and home exercise adherence if discussed] (One to three sentences. If no new information: "No new complaints; status unchanged since last visit.")

Objective

Group Context: [Brief overview of general group activities—warm-up, main exercises, cool-down—for context only]

Patient-Specific Skilled Interventions: [Describe individualized skilled care provided: cueing type and frequency, task modifications, assistance level, manual facilitation, safety management, and how this patient's program differed from the group protocol. Include relevant dosage—time, distance, reps, water depth, equipment used.] (Focus on clinical judgment and skilled actions that distinguish this from general exercise.)

Tolerance and Response: [Pain before/after, RPE or fatigue level, rest breaks required, adverse events or early termination with reason] (Use specific observations; if measures not obtained, state why.)

Assessment

[Response to today's session compared to prior visits; progress toward specific goals with measurable evidence; skilled justification explaining why this patient requires skilled therapy and why aquatic format remains appropriate; barriers to progress if present] (This section should clearly demonstrate why the session was not simply a general exercise class.)

Plan

[Next session focus and planned progressions/regressions; home program updates or patient education provided; interdisciplinary communication if performed; indication for switching to individual sessions if applicable] (Do not repeat frequency/duration unless changed from POC.)

Clinician Signature: [Name, credentials, signature]

Supervising Clinician Attestation: [Supervising clinician statement and signature] (Include only for assistant-delivered or student-involved care.)