Horticultural Therapy Session Note (SOAP)

Participant: [full name, MRN or program ID, DOB or age]

Date of Service: [date]

Session Time/Duration: [start-end time or total duration]

Setting: [indoor greenhouse / outdoor garden / bedside / community site]

Format: [Individual / Group] (If group, include number of participants)

Provider: [name, credentials, role]

Precautions: [relevant safety considerations today] (If none additional, write "Standard safety protocols followed")

Subjective

[Participant-reported experience and priorities] (Include stated goals, symptoms affecting participation, perceived status since last session, and preferences for today's activities. Use direct quotes sparingly for high-value statements. If provided by caregiver or staff, label source. If unable to obtain, state reason briefly.)

Objective

Intervention: [session theme/modality, therapeutic targets, and tasks performed] (Note any grading, progression, or regression applied with rationale.)

Assistance & Adaptations: [assistance level using standardized scale; cueing type and frequency; adaptive equipment or modifications with rationale]

Response: [observable participant response across cognitive, physical, and psychosocial domains as relevant] (Use behaviorally anchored observations with objective data—counts, time, accuracy, assistance level—for goal-aligned measures. Avoid interpretive labels.)

Safety/Adverse Events: [event description and actions taken] (If none, write "No incidents observed")

Assessment

[Clinical synthesis of session tolerance compared to prior session: improved / stable / declined] (Provide brief supporting reasons tied to Objective findings.)

Goal Progress:

• [Goal 1] — [met / partially met / not met] (Compare to baseline or last session using same metric)
• [Goal 2] — [met / partially met / not met] (Add additional goals as needed)

Barriers & Facilitators: [factors limiting or supporting progress] (If applicable)

Skilled Justification: [rationale for grading decisions, safety monitoring, or strategy training] (Tie inferences to Objective observations.)

Plan

Next Session: [focus area tied to goals; planned grading changes]

Safety Plan: [changes for next session regarding weather, tools, staffing, or monitoring] (If none, write "No changes indicated")

Coordination: [team communication, caregiver education, equipment requests] (If applicable)

Carryover: [home or between-session activity assigned] (If none, write "Not assigned")

Discharge Planning: [criteria, timeline, community linkage, home program] (Include when applicable)

Provider Signature: [name, credentials, date/time signed]