Hippotherapy Treatment Session Note (Mounted Equine Movement)

Patient: [name/ID per facility policy]

Date of Service: [date]

Location: [arena/site]

Discipline: [OT / PT / SLP]

Therapist: [name, credentials]

Treatment Time: [total minutes] / [timed code minutes] (If time data unavailable, flag note as INCOMPLETE.)

Team: [horse ID], [handler], [sidewalker(s)]

Pre-Session Safety

[Interval changes since last visit], [contraindication screening result and clearance decision], [safety equipment used], [readiness statement]. (If converted to unmounted session, document reason. Summarize only patient-specific findings; do not include exhaustive contraindication lists.)

Subjective

[Patient/caregiver report of chief concern, pain, fatigue, fear/anxiety, recent changes, and carryover since last visit]. (Use 2–4 sentences. Note information source if patient is nonverbal. Include direct quotes only when clinically relevant.)

Objective

(Document items performed this session. Omit elements not applicable; do not write "N/A".)

• Equine movement dose: [gaits used], [tempo/speed], [total mounted minutes], [transitions with count], [directionality], [patterns/figures], [therapeutic stops with purpose].
• Positioning: [position type], [duration], [supports/adaptive tack], [assistance level], [position changes with rationale].
• Skilled facilitation: [therapist handling at contact points], [cueing type and fading strategy], [task grading/progression], [handler instructions with clinical rationale]. (Document specifics that distinguish skilled therapy from recreational riding.)
• Functional activities: [activity with linked goal], [measurable performance: reps/time/accuracy/assistance level], [how equine movement addressed this target]. (Repeat for each activity.)
• Patient response: [tolerance indicators], [pre/post measures if obtained], [safety events and actions taken]. (If safety event occurred, document clinical facts here in addition to any incident report.)

Assessment

[Progress toward goals compared to prior session], [how equine movement dose and positioning influenced performance], [barriers encountered and management], [justification for ongoing skilled services]. (Avoid vague statements; tie interpretation to objective data.)

Plan

• Next session: [planned progressions to equine parameters, positioning, or team support], [safety considerations].
• Home program: [1–3 items with frequency/duration and safety setup]. (Omit if none assigned.)
• Coordination: [caregiver education, equipment needs, medical follow-up as applicable]. (Omit if none.)