Ground-Based Equine-Assisted Activity Session Note

Date of Service: [Date]

Patient: [Patient full name / ID]

Provider/Credentials: [Provider name, license/credentials]

Service Type: [Licensed discipline (e.g., OT/PT/SLP/Behavioral Health/RT)] — [individual / group]

Location/Setting: [Facility/area (e.g., arena/barn aisle/paddock)]

Equine/Handler: [Horse name/ID]; [Handler name]; [Additional personnel as relevant]

Goals Addressed: [1–3 POC goals targeted this session]

Session Focus

[2–3 sentence statement of skilled therapeutic intent explicitly naming the licensed discipline and linking selected ground-based equine tasks (e.g., grooming, leading, obstacle negotiation) to targeted functional impairments and goals.] (Avoid vague phrasing; clearly state why the equine context and specific tasks are indicated for this patient.)

Subjective

[Patient and/or caregiver report: relevant symptoms, recent falls or health changes affecting safety, perceived progress, engagement factors; key quotes only as needed.] (If no subjective information was obtained, state: "Not reported today.")

Objective

Pre-session safety/readiness: [Patient screening (symptoms/behavioral readiness, precautions reviewed), environment conditions, equipment check, equine status/temperament, staffing/guarding arrangement.] (If no issues identified, a brief statement such as "Pre-session safety check completed; environment controlled; equine calm; handler present; no hazards identified" is acceptable.)

Interventions and performance: (For each activity or goal addressed, document the following elements in narrative or structured format as appropriate.)

• [Activity/Goal]: [Task performed and dose (time/reps/distance)]; [Grading/adaptations applied]; [Skilled clinician actions: cueing type/frequency, facilitation, guarding, error correction, motor learning strategies]; [Patient performance: assistance level, accuracy, safety behaviors, measurable outcomes]. (Use standard assistance terminology: Independent, Supervision, Stand-by Assist, Contact Guard Assist, Min/Mod/Max Assist. Quantify when possible. Add additional activity blocks as needed.)

Adverse events/near misses: [What happened, immediate response, patient status afterward, notifications made, follow-up actions.] (If none occurred, state: "No adverse events or near misses.")

Assessment

[Clinical interpretation: patient response to interventions; progress toward each goal with supporting evidence; clinical factors affecting performance (pain, fatigue, behavioral regulation, environmental constraints); justification for ongoing skilled therapy.] (Avoid conclusory statements without data. If no progress, document plausible reasons and planned modifications.)

• [Goal 1]: [improved / stable / regressed] — [Brief evidence-based rationale]
• [Goal 2]: [improved / stable / regressed] — [Brief evidence-based rationale] (Include only if addressed)

Plan

• Next session: [Planned progression/regression of tasks with rationale]
• Safety modifications: [Environment/equipment/staffing adjustments, if any]
• Home program/carryover: [Carryover tasks or caregiver training] (Include only if applicable)
• Coordination: [Communication with other providers; POC updates initiated] (Include only if applicable)

Time In / Time Out: [HH:MM] / [HH:MM]

Total Timed Minutes: [Minutes]

CPT Codes/Units: [Codes and units] (Ensure consistency with documented interventions and time.)

Signature/Credentials: [Provider signature and credentials]

Date/Time: [Date and time of signature]

Co-signature: [Supervising provider name/credentials and attestation] (Include only if assistant or trainee participated requiring supervision.)