Equine Therapy Session Note (SOAP)

Patient: [Patient full name] | DOB: [Date of birth] | MRN/Chart ID: [Record identifier]

Date of Service: [Date] | Start: [Start time] End: [End time] | Total Treatment Time: [Total minutes]

Location: [Facility/Program] | Setting: [Indoor arena / Outdoor arena / Barn / Mounting area / Clinic room]

Discipline: [OT / PT / SLP] | Visit Type: [Initial evaluation / Follow-up / Progress note / Re-evaluation / Discharge]

Rendering Clinician: [Clinician name, credentials] | Ordering/Referring Provider: [Name, credentials / not required]

Session Modality: [mounted / unmounted equine-facilitated / combined / equine deferred] | Primary Diagnosis: [Diagnosis/problem]

Subjective

[Information source and capacity]. [Interval changes since last visit relevant to treatment: pain, fatigue, tone, seizures, falls, functional changes, medication changes, home program adherence] (Include only if explicitly reported; use "not reported today" or "not assessed" when applicable). [Today's precautions or restrictions]. [Equine-related considerations: comfort with mounting, sensory sensitivities, motion tolerance] (Include only if relevant). (Do not infer symptoms not assessed or state denials unless explicitly asked and answered.)

Objective

Safety and Equine Context: (Include when equine contact occurred) [Medical readiness confirmed; precautions reviewed; PPE verified; environment conditions; tack/equipment check; mount/dismount method; horse identifier; horse movement quality or behavior relevant to session; team members with roles; patient positioning during mounted work]. (If equine deferred, state rationale and alternative interventions provided.)

Skilled Interventions: (For each intervention, document the following in narrative or brief list format) [Goal addressed; therapist's skilled actions and clinical reasoning including facilitation, grading, cueing type, task modification, manipulation of equine movement parameters; dose and intensity; assistance and cue level; objective outcomes including postural responses, balance reactions, ROM, strength, communication accuracy, swallow function, or other discipline-specific measures; response to graded demands].

Time and Billing: Total timed treatment minutes: [Minutes]. CPT codes billed: [Code – Units] (Ensure alignment with documented interventions.)

Assessment

[Clinical reasoning in 4–8 sentences: Response to today's treatment tied to goals; measurable progress compared with last session or baseline; skilled justification explaining why therapist expertise was required; contribution of equine movement or environment to observed outcomes when applicable; barriers, risks, or incidents encountered with mitigation steps; tolerance with objective anchors such as duration tolerated and rest breaks needed]. (Use only information supported by the session; do not infer.)

Plan

• Next visit focus: [Goals to prioritize and rationale; planned progression or regression of equine parameters and task demands].
• Home program: [Exercises or activities with frequency, safety precautions, caregiver instructions] (Include only if assigned).
• Coordination: [Caregiver, team, or physician communication needs; upcoming progress report or reevaluation] (Include only if applicable).

Adverse Event

(Include this section only if an adverse event occurred)

Time: [Time of event]. Event: [Factual description: fall, unplanned dismount, injury, seizure, allergic reaction, horse incident, session termination for safety]. Actions taken: [Immediate interventions provided]. Notifications: [Who was notified and when]. Disposition: [Return to activity / modified activity / sent home / EMS activation / ED referral]. Incident report: [Completed / Not applicable].

Signature: [Primary author name, credentials] | Date/Time Signed: [Date, time]

(If assistants contributed) [Assistant name(s), role(s)] — [Supervising therapist attestation per policy].