Horticultural Therapy Incident/Injury Note

Event Date/Time: [date and time of occurrence or best estimate]

Documentation Date/Time: [auto-captured; if entered late, label as "Late Entry" and reference actual event date/time]

Author: [name, credentials, discipline, supervising clinician if applicable]

Setting/Location: [e.g., inpatient psychiatry garden, SNF courtyard, greenhouse]

Session Type: [individual / group]; [planned activity]; [supervision ratio and staff present]

(Use objective, factual language throughout. Avoid speculation or attributing fault. Clearly label uncertainty and attribute sources [patient report / staff report / direct observation]. If critical information is unknown, document "Unknown" with reason. Use local time with timestamps for key events.)

Event Description

Event Category: [tool-related injury / fall or near-fall / behavioral escalation / allergic reaction or exposure / environmental exposure / other—specify]

Event Type: [incident (reached patient) / near miss / unsafe condition]

Witness Status: [witnessed / unwitnessed / partially witnessed]; [who witnessed if applicable]

Initial Harm Level: [no apparent harm / minor (first aid only) / moderate (requires clinical evaluation or increased monitoring) / severe (ED transfer, significant injury) / death] (Note if evolving.)

Chronological Narrative: [Lead sentence with date/time, location, and what occurred. Time-sequenced account of: activity at moment of event; equipment/materials involved; relevant environmental conditions; mechanism details tailored to event type; patient-reported symptoms with direct quotes when clinically important. If unwitnessed, include last known well time and condition on discovery.]

Assessment & Response

Baseline Prior to Event: [relevant observations immediately before the event: mobility aids, cognition/behavior, relevant symptoms, applicable allergies or precautions] (Include only what is directly relevant.)

Safety Controls in Place: [PPE, tool briefing, environmental setup, adaptive tools, staffing configuration]

Subjective: [pain score and location; relevant symptoms; emotional distress; patient's account of the event; for behavioral events include stated intent or triggers]

Objective: [vital signs or "not obtained" with reason; mental status; focused exam findings appropriate to event type] (Document only what was assessed.)

Impression: [brief clinical impression using cautious language] (Do not overstate certainty.)

Interventions: [first aid and clinical care with timestamps; session modifications; patient response] (If patient refuses assessment, document what was explained, capacity concerns if any, what was declined, and what could still be observed.)

Notifications

• [who notified, role, date/time, method, key content communicated, guidance received]
• [family/guardian if applicable: who, relationship, date/time, method, information provided, agreed follow-up]
• [administrative/safety reporting per policy: system used, report ID if applicable]

Care Transfer/Handoff: [receiving clinician/service, date/time; current condition, red flags, required monitoring, restrictions, pending items, current location] (Include only if care was transferred.)

Outcome & Plan

Immediate Outcome: [condition at end of encounter; pain level if relevant; disposition]

Monitoring: [what to monitor and frequency/duration if specified]

Follow-up: [referrals, orders, appointments, pending tasks]

Return-to-HT Guidance: [hold participation / allow with restrictions—specify restrictions, duration, and criteria for lifting]

Prevention Plan Updates: [changes to patient-specific precautions and environmental/process updates; note who was informed and where updated. If no changes: "No changes to HT safety plan at this time; will monitor."]

Restraint/Seclusion: [order details; time-limited start/stop; monitoring intervals; face-to-face evaluation; alternatives attempted; clinical rationale; release criteria; debriefing] (Include only if restraint or seclusion occurred; document per facility policy and regulatory requirements.)

Signature: [name, credentials] — [date] [time]

(For later additions, label as "Addendum" with current date/time referencing the original event. Do not backdate or delete original content.)