Equine Therapy Progress Report (10th Visit/30-day)

Patient/Case Information

Patient Name: [Patient full name]

DOB: [MM/DD/YYYY]

MRN: [Medical record number]

Treating Discipline: [PT / OT / SLP / RT]

Primary Diagnosis: [ICD-10 description/code]

Referring Provider: [Name, credentials]

Report Date: [MM/DD/YYYY]

Reporting Period: [Start date] to [end date]

Visit: #[Current visit number] of [total authorized]

Treatment Days This Period: [Number of treatment days]

Initial Evaluation Date: [MM/DD/YYYY]

POC Certification Period: [Start date] – [end date]

Recertification Requested: [Yes / No]

Current Precautions: [Fall risk, weight-bearing status, seizure precautions, behavioral/sensory considerations, allergies, helmet requirements] (If none, enter "None identified"; use "Not on file" for any required field where information is unavailable)

Clinical Summary

[Concise summary paragraph of 3–6 sentences covering: baseline functional limitation with reference date; key objective changes since baseline and since last report using 1–3 metrics; goal attainment status; statement of continued skilled need; and any POC changes requiring recertification] (If true baseline unavailable, explicitly state the reference date used instead.)

Subjective

[Patient/caregiver-reported functional changes, symptom status, home program adherence, attendance barriers, intercurrent events, and updated priorities] (Use brief bullets; include direct quotes only when clinically meaningful. Document "Not assessed" for expected items not obtained rather than assuming status. Do not infer adherence or symptoms—report only what was stated.)

Objective

Outcome Measures:

Measure	Baseline	Prior Report	Current	Change/Comments
[Standardized measure name]	[Value/Date]	[Value/Date]	[Value/Date]	[Clinical significance; if not repeated, state reason]
[Standardized measure name]	[Value/Date]	[Value/Date]	[Value/Date]	[Clinical significance; if not repeated, state reason]

(Use standardized measures appropriate to discipline: TUG, Berg, gait speed, GMFM, PEDI-CAT, etc.)

Functional Status: [Current function versus baseline across relevant domains—transfers, gait/mobility, balance/postural control, strength/ROM/tone, ADLs/communication as applicable] (Use measurable anchors: distance, time, device, assistance level. Address only domains assessed.)

Equine Component: [Number of equine-integrated sessions; horse/movement characteristics; patient positioning; equipment/adjuncts; mounted time; key clinical responses including postural activation, balance reactions, motor planning, regulation; adverse responses or safety actions if any; suitability statement] (Include only if equine sessions occurred this period. Document equine movement as a therapeutic tool within skilled therapy, not as a separate service. If not utilized, state rationale in Plan.)

Assessment

Goal Progress:

• Goal: [Goal statement]
  Baseline → Current: [Baseline metric] → [Current metric]
  Status: [Met / Progressing / Not Met / Revised]
  (If revised, state prior goal and rationale for change)
• Goal: [Goal statement]
  Baseline → Current: [Baseline metric] → [Current metric]
  Status: [Met / Progressing / Not Met / Revised]

Clinical Interpretation: [Synthesis of what objective changes mean functionally; remaining activity limitations and impairments affecting participation and safety] (Avoid repeating raw data.)

Skilled Need Justification: [Why ongoing skilled therapy is required: complexity, safety considerations, clinical reasoning for progression/dosing/adaptation, integration of equine movement, and why services cannot be performed by unskilled personnel or independently] (If progress is limited, provide clinical rationale and state whether goals remain attainable.)

Plan

Therapy Plan: [Continue / Modify / Discharge] — [Frequency and duration until next review; primary intervention focus; whether equine component will continue, be modified, or paused with rationale]

Home Program: [Updates, caregiver training provided, adherence barriers being addressed]

Care Coordination: [Communication with physician/team, referrals recommended, equipment needs]

POC Update for Recertification: (Include only if recertification requested)

• Effective Date: [MM/DD/YYYY]
• Updated Diagnoses: [Diagnosis/ICD-10 or "No change"]
• Updated Long-Term Goals: [Functional goals with measurable criteria and timeframe]
• Type/Frequency/Duration: [Discipline, visits/week, total weeks] (Indicate planned use of equine movement as treatment tool)
• Therapist Signature: __________________ Date: __________
• Physician/NPP Signature: __________________ Date: __________

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Therapist Name, Credentials: [Name, degree(s), license]

Signature: __________________

Date/Time: [MM/DD/YYYY HH:MM]

Supervising Clinician: [Name, credentials] (Include only if supervision required by discipline or payer)

Safety Incident Addendum

(Include only if a safety incident occurred during the reporting period: fall, emergency dismount, equipment failure, adverse horse behavior, or medical event)

• Event Description: [What occurred, when, where]
• Immediate Response: [Actions taken, assessment findings, notifications]
• Outcome: [Injury status, return-to-therapy decision]
• Plan Modifications: [Changes to precautions, equipment, horse selection, environment, staffing]