Horticultural Therapy Discharge Summary

Date of Discharge: [Date]

Participant Name: [Full name]

Date of Birth: [DOB]

Record ID: [Medical record or program ID]

Service Setting: [outdoor garden / greenhouse / bedside / clinic / community program]

Episode Dates: [Start date] – [End date]

Sessions Completed: [Number of sessions] [Frequency pattern, e.g., 2x/week]

Clinician Name and Credentials: [Name, credentials]

Discharge Summary

[Executive synopsis of episode] (Write 1–3 concise paragraphs summarizing: presenting needs addressed; major intervention themes delivered; overall pattern of goal achievement; reason services ended; headline aftercare recommendations. Use clinically specific but plain language accessible to interdisciplinary readers. Clearly distinguish clinician observations from participant-reported statements.)

Reason for Discharge

Discharge Type: [planned completion / unplanned / participant request / transfer / administrative] | Date: [Date]

[Brief explanation of discharge circumstances] (If unplanned, include last successful contact date and note barriers to obtaining complete information.)

Baseline Status at Start of Services

(Summarize the functional starting point using brief bullets. Include objective anchors where available such as standardized measure scores, observed task performance levels, or assistance levels required.)

• Physical/Motor: [Standing tolerance, reach/grip, endurance, mobility or positioning needs, assistance level]
• Cognitive/Behavioral: [Attention, sequencing, safety awareness, frustration tolerance, memory/organization]
• Psychosocial: [Baseline affect, engagement level, social interaction patterns, motivation]
• Precautions/Restrictions: [Fall risk / immunocompromised / weight-bearing / skin integrity / photosensitivity / tool use limitations] (Omit if none.)
• Standardized Measures at Baseline: [Measure name and score] (Include only if obtained; otherwise omit this bullet.)

Course of Horticultural Therapy Services

Service Delivery: [Frequency], [Duration per session], [Group / individual / mixed], [Setting], [Mode adjustments if applicable]

Core Approaches: [Intervention approaches used, e.g., activity grading, sensory modulation, social participation facilitation, task adaptation, vocational components, pacing strategies]

Representative Therapeutic Activities: (List activity–goal pairs.)

• [Activity] — targets: [Functional goals addressed]
• [Activity] — targets: [Functional goals addressed]
• [Activity] — targets: [Functional goals addressed]

Key Adaptations and Environmental Modifications:

• Adaptive tools: [Tools and aids used]
• Accessibility supports: [Environmental modifications for access]
• Cognitive supports: [Cueing systems, checklists, visual aids]
• Behavioral supports: [Regulation strategies, structure, reinforcement] (Omit categories not applicable.)

Reproducible Setup Notes: [Positioning, height, tool placement, cueing pattern, and pacing that enabled success] (Include enough detail that effective strategies could be reproduced.)

Outcomes at Discharge

(Present each goal with baseline, discharge status, determination, and supporting evidence. Sort by clinical priority.)

• Goal 1: [Goal statement]

  • Baseline: [Baseline status/measure/assistance level]
  • Discharge Status: [Current status/measure/assistance level]
  • Outcome: [met / partially met / not met / unable to assess]
  • Evidence: [Measure score change, observed task performance, frequency/duration data, level of cueing or assistance]
  • If not met—Primary reason: [Reason] (Omit this line if goal was met.)

• Goal 2: [Goal statement]

  • Baseline: [Baseline status]
  • Discharge Status: [Current status]
  • Outcome: [met / partially met / not met / unable to assess]
  • Evidence: [Supporting data]
  • If not met—Primary reason: [Reason] (Omit this line if goal was met.)
• (Repeat goal block for additional goals as needed.)

Functional Status at Discharge vs Baseline: [Concise narrative comparing motor/physical function, activity tolerance, cognitive task performance, social participation, emotional/behavioral regulation] (Use "as evidenced by" descriptors tied to observations or measures.)

Standardized Measures: [Measure name] — Baseline: [Score], Discharge: [Score] (Include only if measures were administered; otherwise omit. If a planned measure was not completed, note why.)

Participant-Reported Outcomes: [Brief direct quote or paraphrase, labeled as participant report] (Include only if clinically meaningful; otherwise omit.)

Safety Considerations

[Adverse events summary] (Document any adverse events or near-misses and effective mitigation strategies. If none occurred, state: "No adverse events observed during this episode.")

Ongoing Participation Guidelines:

• Recommended supervision level: [independent with setup / distant supervision / close supervision / contact guard / avoid unsupervised tool use]
• Tool safety: [Approved tools, tools to avoid, protective equipment, safe body mechanics]
• Environmental precautions: [Heat/sun management, hydration, terrain stability, allergen exposure, infection control, time-of-day recommendations]

Effective Strategies

(List 3–7 high-yield activities/strategies with rationale and setup details so others can reproduce.)

• [Strategy/Activity]: Rationale: [Link to goal/symptom addressed]; Setup: [Tools, positioning, cues]; Engagement factors: [Preferred plant types, sensory preferences, group vs individual]
• [Strategy/Activity]: Rationale: [Reason]; Setup: [Details]; Engagement factors: [Details]
• [Strategy/Activity]: Rationale: [Reason]; Setup: [Details]; Engagement factors: [Details]

Barriers and Unmet Needs

(Include this section only if one or more goals were partially met or not met; otherwise omit entirely.)

• Barriers encountered: [Attendance/transportation, cognitive symptoms, medical factors, environmental limits, equipment access, psychosocial factors]
• What was attempted: [Adaptations, education, outreach, scheduling changes, referrals tried]
• Current risks/limitations: [What remains unsafe or not yet independent]
• Recommended next steps: [Referrals or services recommended: OT, PT, behavioral health, case management, community programs, adaptive gardening resources]

Aftercare Plan

Recommended Activities: [Activity types] — Frequency: [x/week], Duration: [minutes/session], Progression: [How to increase complexity safely]

Setup and Safety: [Tools needed, seating/positioning, hydration/timing, sun/heat protection, supervision level]

Caregiver Training: [Who was trained], [Skills taught], [How understanding was verified], [Cueing strategies], [When to stop and seek assistance] (Include only if caregiver training was provided; otherwise omit.)

Resources Provided:

• Written materials: [Handouts, visual sequences, plant care guides provided]
• Community resources: [Community gardens, adaptive gardening programs, therapeutic recreation, Master Gardener/extension contacts with access information] (If no appropriate resources were identified, note limiting factor.)

Clinician Signature

[Clinician Name, Credentials] ________________________________ Date: [Date]

(Documentation guidance: Use "Unknown" only for required fields when information should exist but could not be obtained—add a brief qualifier explaining why. Use "Not assessed" when clinically relevant but not measured this episode. Avoid vague terms like "improving" without supporting evidence. Clearly label participant-reported statements throughout.)