Equine Therapy Plan of Care

Patient Name: [Patient full name]

Date of Birth: [MM/DD/YYYY]

MRN/ID: [Medical record number or unique ID]

Date of Evaluation: [MM/DD/YYYY]

Date of POC: [MM/DD/YYYY]

Treating Discipline: [PT / OT / SLP]

Clinician Name and Credentials: [Clinician name, credentials, license number]

Facility/Service Location: [Equine facility and/or clinic name, address]

Referring Provider: [Provider name, credentials, NPI, contact] (If unknown, write "Pending—request sent [date]")

Payer and Authorization: [Payer name; member ID; authorization number and approved visits] (Omit if not applicable)

Referral Basis

[Reason for referral; chief functional concern in patient-centered language; date of onset; prior vs. current level of function] (If this POC accompanies a full evaluation note, abbreviate to a single line referencing that evaluation.)

Diagnoses and Therapy Problems

Medical Diagnosis(es): [Confirmed diagnosis(es) with ICD-10 code(s)] (If not provided, write "Medical diagnosis pending—therapy problems identified include [list]—diagnosis request sent [date]." Never list uncertain diagnoses as confirmed.)

Therapy Problems:

• [Impairments relevant to PT/OT/SLP scope]
• [Activity-level functional limitations]
• [Participation restrictions]
• [Relevant comorbidities affecting safety, prognosis, or treatment] (Only include if they directly impact care.)

Baseline Summary

[Key functional limitations at activity/participation level; key impairments at body structure/function level; standardized outcome measures with scores and interpretation; factors affecting care such as cognition, behavior, learning barriers, or attendance constraints] (If full evaluation is attached, include a concise reference and highlight only key findings supporting goals.)

Precautions and Safety

• [General precautions: falls risk, seizure history, cardiac/pulmonary precautions, surgical precautions, osteoporosis, skin integrity, pain limits, cognitive/behavioral factors] (List only those relevant to this patient.)

Equine Environment Safety

• Allergies/asthma triggers: [Hay, dander, dust sensitivities] (If unknown, write "Unknown—to be confirmed before first equine session.")
• Helmet and footwear: [Requirements per program policy; compliance and fit-check plan]
• Mount/dismount: [Method (ramp/lift/block); supervision level; number of side-walkers]
• Emergency plan: [Seizure protocol, behavioral escalation plan, emergency dismount strategy as applicable]
• Team roles: [Therapist, equine handler, side-walker responsibilities; communication signals]

Prognosis and Skilled-Need Rationale

Rehabilitation potential: [good / fair / guarded] — [Rationale tied to baseline status, comorbidities, motivation, and supports]

Why skilled therapy is required: [Clinical complexity requiring ongoing assessment; safety management in equine environment; need for modification of equine movement parameters; postural/neuromotor facilitation; graded task progression; integration with discipline-specific interventions requiring a licensed therapist; anticipated response timeline; limiting factors]

Goals

Long-Term Goals (Required. State functional goals at activity/participation level with measurable criteria and timeframe.)

1. LTG-1: [Functional target tied to real-world need] — [Measurable criteria: distance/time/assistance level/accuracy] — [Timeframe] — Baseline: [Current status]
2. LTG-2: [Functional target] — [Measurable criteria] — [Timeframe] — Baseline: [Current status]

(Add additional LTGs as needed. If baseline cannot be measured at evaluation, document why and when measurable baseline will be established.)

Short-Term Goals (Include when episode exceeds 2–3 weeks, multiple domains are addressed, or payer scrutiny is anticipated.)

1. STG-1 → LTG-1: [Intermediate functional milestone] — [Measurable criteria] — [Timeframe] — Baseline: [Current status]
2. STG-2 → LTG-2: [Intermediate functional milestone] — [Measurable criteria] — [Timeframe] — Baseline: [Current status]

Services Plan

(Document Type, Amount, Frequency, and Duration for each discipline.)

• Type: [PT / OT / SLP] — [Intervention category: neuromuscular re-education / therapeutic activities / ADL training / language intervention / AAC / gait training / balance training]
• Amount: [Sessions per treatment day]
• Frequency: [Visits per week] (If tapering, document beginning and ending frequency.)
• Duration: [Number of weeks or total visits]
• Service Location: [Equine facility / clinic / community]
• Format: [individual / group]
• Authorization status: [Approved parameters] or [Pending—interim plan: [TAFD]; requested [date]] (Omit if not applicable.)

Planned Interventions

(List interventions by goal or problem area with key parameters.)

• For LTG-1: [Intervention approaches and key parameters/progression criteria]
• For LTG-2: [Intervention approaches and key parameters/progression criteria]

Equine Movement Integration

(Include only when equine movement will be used. Document as treatment tool within PT/OT/SLP, not a standalone service.)

• Therapeutic rationale: [Why equine movement is indicated for this patient's impairments and goals]
• Positioning strategies: [Sitting astride / side-sitting / prone / supine / tall-kneeling; equipment (pads/surcingle/reins); therapist contact points]
• Task demands and progression: [Speed changes; direction changes; halt/walk transitions; figure patterns; inclines; dual-tasking; reaching; criteria for progression/regression]
• Data collection: [Session metrics to record mapped to corresponding goals]

Home Program and Caregiver Training

[Home exercises; positioning strategies; ADL/communication/swallow carryover; recommended equipment or environmental modifications; caregiver training plan and competency verification method] (Omit this section if no safe home tasks are appropriate at this time.)

Discharge Criteria

• All established goals met
• Plateau or maximum benefit reached
• Safe transition to home program and/or community resources
• Need for different level of care identified
• Attendance or medical barriers prevent progress

Anticipated discharge timeframe: [Estimated date or number of weeks/visits]

Certification and Transmission

• Certification required: [Yes / No / Pending verification] — Basis: [Medicare Part B / Medicaid / commercial / self-pay]
• Certification method: [Signed POC returned [date] / Verbal certification [date] with follow-up signature plan / Order on file with POC transmitted within required timeframe / Physician note indicating approval]
• Recertification due: [MM/DD/YYYY] (Earlier if LTGs change significantly.)

Transmission log:

• [Date] — [Recipient] — [Method: EHR / secure email / fax] — [Confirmation] — [Within required timeframe: Yes/No]

Established By

Therapist Signature: ________________________________

Name, Credentials, License #: [Name, credentials, state license number]

Date: [MM/DD/YYYY]

Version: v1.0 (Update version number if goals or duration change significantly.)