Inpatient Medical Unit Note (Art Therapy)

Date/Time: [Date and time; start–end or total duration per local policy]

Location: [Unit and room; bedside / therapy space]

Encounter Type: [initial / follow-up; individual / group]

Provider: [Name, credentials, and supervisory status if trainee]

Referral Source: [Consulting service and brief referral reason, if applicable]

Safety and Feasibility

[Clinical readiness to participate; relevant precautions or medical factors; materials restrictions for safety or infection control; others present if relevant to encounter] (Document briefly. If patient was not seen, state the reason and reattempt plan, then omit remaining sections.)

Subjective

Encounter Focus: [One-sentence clinical goal for today's session]

Patient-Reported: [Stated priorities or concerns; self-reported symptoms with numeric ratings if obtained; consent and preference for artmaking; brief direct quotes when clinically useful] (If subjective data were not obtainable, explicitly document the reason.)

Objective

Presentation: [Alertness; affect; visible distress cues]

Engagement and Capacity: [Attention; initiation; frustration tolerance; communication method; bedside factors that impacted participation]

Intervention Provided: [Intervention type and clinical rationale; directive or prompt used; materials and media; adaptations for bedside constraints; coping or grounding techniques integrated]

Artwork: [Neutral, non-interpretive description of visible elements; patient's own interpretation if shared; disposition of artwork] (Omit if no artwork created.)

Assessment

[Brief clinical impression synthesizing the session; patient response during and after intervention with observable changes; post-session symptom ratings if reassessed; progress toward referral goals; coping strengths and barriers identified; clinical reasoning for intervention choice and how response informs future sessions] (Avoid interpretive claims about symbolism unless directly attributed to patient. Document any safety concerns observed, actions taken, and team notifications.)

Plan

Follow-Up: [Timing and frequency of sessions]

Next Session Focus: [Planned therapeutic focus]

Patient Practice: [At-bedside coping strategy or resource] (Only include if applicable.)

Team Communication: [Who was contacted and key information shared] (Only include if clinically significant.)

Discharge/Handoff: [Handoff recommendations or referrals] (Only include if approaching discharge.)

(For a final visit or discharge from art therapy services, replace the above with a brief summary of the course of treatment, effective coping strategies identified, and disposition of any retained artwork.)