Horticultural Therapy Re-Evaluation/Progress Report

Patient: [name, MRN, DOB per facility policy]

Date: [date authored]

Author: [name, credentials]

Setting: [location/program type]

Reporting Period: [start date] – [end date]

Encounters: [number completed] completed; [number planned] planned; [missed sessions with reasons if relevant]. Mode: [group / individual]; Location: [greenhouse / garden / bedside / classroom / virtual]. (List session dates if required by facility policy. Note cancellations/no-shows with reasons when relevant to access, safety, or outcomes.)

Reason for Report

[scheduled interval summary / payer or authorization requirement / change in participant status / plateau or regression requiring plan revision / transition or discharge planning / safety concern / formal re-evaluation] (Briefly state the trigger. If a formal re-evaluation was performed, specify why reassessment was necessary and what clinical decisions it informed.)

Subjective

[Participant-reported status during the reporting period] (Summarize perceived changes, current priorities, satisfaction with therapy, and self-reported symptoms impacting participation such as mood, fatigue, pain, or motivation. Include home/community carryover of skills if reported. Add one concise direct quote only when it adds clinical salience. If subjective information cannot be obtained due to cognitive or communication limitations, document the reason and how status was inferred from observation.)

Objective

Interval History: [significant changes since last report] (Include only changes that affected participation, safety, or outcomes—new medical/psychiatric events, medication changes impacting function, new precautions, or environmental changes. Omit this field if no relevant changes occurred.)

Outcome Measures: [measures administered with dates, baseline values, current values, and interpretation] (Use standardized tools when available. For clinic-defined metrics, maintain consistency and define scoring anchors. Link interpretation to functional impact.)

Functional Observations: [quantified observations across relevant domains—participation/engagement, psychomotor/physical function, cognitive/executive function, affective/psychosocial function, horticultural task performance] (Use observable data tied to session dates: cueing levels, accuracy percentages, time to complete, repetitions, assist levels. Avoid vague descriptors like "tolerated well." Include safety incidents, near-misses, or risk-relevant behaviors with dates and corrective actions.)

Assessment

Goal Status:

• Goal [ID]: [goal statement]. Baseline: [metric, date]. Current: [metric, date]. Status: [Met / Progressing / Not progressing / Regressed / Discontinued]. (Tie status to objective evidence. If revised or discontinued, state rationale.)
• Goal [ID]: [goal statement]. Baseline: [metric, date]. Current: [metric, date]. Status: [Met / Progressing / Not progressing / Regressed / Discontinued].
• (Add additional goals as needed.)

Clinical Interpretation: [overall trajectory: improving / mixed / plateau / decline] (Synthesize how outcome measures and functional observations support the trajectory. Identify primary factors supporting progress and key barriers limiting progress. If plateau or regression is present, explain contributing factors and adjustments trialed or planned. Document clinical reasoning regarding grading of activities, safety monitoring, and why skilled judgment is required.)

Plan

Disposition: [Continue services / Modify plan of care / Transition / Discharge] (Include brief rationale linked to objective data and goals.)

Updated Plan of Care: [frequency and duration for next interval; intervention focus areas linked to goals; new or revised outcome measures; home program or between-session assignments; coordination with other providers or caregivers] (Note planned progression or adaptations.)

Medical Necessity Statement: [objective impairments or risks requiring skilled horticultural therapy; what participant would be at risk for without continued services] (Include when payer-facing, authorization-driven, or when progress is slow/plateaued. Omit for internal-only reports when services are clearly progressing.)

Discharge Planning: [anticipated discharge criteria or timeline; transition plan to community resources or maintenance programs] (Omit if not applicable to current reporting period.)

Next Report: [date or trigger for next progress report]

Signature: [clinician signature, credentials, date/time]

Co-signature: [supervising clinician signature if assistant or student involvement, per facility policy]