Equine Therapy Re-Evaluation Note

Date of Service: [Date]

Start/End Time: [Start Time – End Time]

Patient: [Patient Full Name]

DOB: [DOB]

Therapist: [Therapist Name, Credentials]

Referring Provider: [Referring Provider Name, Credentials]

Diagnosis: [Primary Diagnosis and Codes] (Include secondary diagnoses only if they impact today's plan.)

Initial Evaluation Date: [Date]

Last Progress Report/Re-Eval Date: [Date]

Session Setting & Team: [Location, team roles present, safety equipment used] (Summarize concisely on one line.)

Reason for Re-Evaluation

[Trigger type: planned interval reassessment / unplanned change due to new status, failure to progress, or need for goal modification]. [Specific trigger description and what clinical decisions this re-evaluation will support.] (Write 2–4 sentences. If triggering information is incomplete, state what is unknown and how this affects today's session plan.)

Interval History

[Patient/caregiver-stated priorities or chief concern] ["Brief direct quote if it captures the patient perspective meaningfully."] [Symptom and functional changes since last evaluation/progress report, including adverse events, falls, or equine-related incidents.] [Relevant medical updates: hospitalizations, medication changes, new precautions.] [Home program adherence and response.] (If safety-relevant information could not be obtained, state what was missing and how this was mitigated.)

Objective Reassessment

Current Precautions: [Precautions and safety considerations relevant to equine participation] (Update for today's session.)

Standardized Measures: [Test name]: [Current score] | Baseline: [Score, Date] → [improved / declined / plateau], [clinically meaningful / not clinically meaningful]. (Repeat per measure as applicable. If a planned measure was not obtained, state reason.)

Systems Findings: [Pertinent findings by domain relevant to discipline—posture/trunk control, balance, mobility, sensory regulation, communication, cognition, etc.] (Include only domains reassessed today with key observations and assistance levels.)

Functional Performance: [Off-horse tasks assessed with assistance levels, devices, and conditions.]

Equine-Specific Findings: [Mounted participation status; mounting tolerance and method; postural control on horse; response to equine movement; supports/adaptations and staffing requirements; relevant equine parameters informing clinical reasoning.] (Include only what was assessed. Note whether gains appear to transfer to off-horse function.)

Assessment

[Clinical synthesis of trajectory across reassessed domains. Interpret the meaning of measured changes and relate findings to functional participation—do not restate raw scores without interpretation.]

[Medical necessity statement explaining why continued skilled therapy is required, prognosis, expected timeframe, and key barriers and facilitators to progress.]

Equine Component Decision: [continuing / modifying / pausing / discontinuing]. [Clinical rationale based on benefit-risk balance, patient response, goal alignment, and generalization evidence.] (If continuing with elevated risk, state risk controls. If discontinuing, specify non-equine interventions that will address the same functional targets.)

Goals & Plan

Goals: (Use consistent identifiers. Mark each existing goal as Met with date, Continued, or Revised with brief rationale. Add new goals only if supported by findings. Goals must be functional, measurable, and include timeframe and conditions.)

• [LTG/STG identifier]: [Goal statement] — Status: [Met (Date) / Continued / Revised]
• (Repeat for each goal)

Plan of Care: Frequency: [x/week]; Duration: [x weeks]; Anticipated visits remaining: [#]. [Identify which goals addressed via equine vs non-equine intervention.]

Home Program Updates: [Brief description of updates to home program or caregiver training] (Omit if unchanged.)

Discharge Criteria & Coordination: [Discharge criteria]; [Coordination needs if applicable: physician follow-up, recertification, team communication]

Therapist Signature: [Therapist Name, Credentials] [Date/Time]