Inpatient Rehabilitation Psychology Progress Note

Date & Time of Service: [Date and time of service]

Provider: [Provider name, credentials]

Patient Identifier: [Patient identifier]

Visit Type: [individual / family / co-treatment / collateral-only / team conference]

Session Duration: [Total minutes]

Supervising Clinician: [Supervising clinician name, credentials] (Only include if trainee documentation requiring co-signature)

Interval Summary

[Brief synopsis of why this follow-up occurred and what has changed since last psychology contact, including engagement and participation trends, mood and adjustment trajectory, safety updates if any, and team-relevant barriers or facilitators affecting therapies and discharge. Reference the initial evaluation date rather than repeating static history.] (Limit to 2–6 lines.)

Subjective

[Patient-reported mood, anxiety, adjustment concerns, sleep, and perceived barriers to therapy participation. Include patient goals and statements about discharge readiness, noting any differences from team goals. Add family, caregiver, or staff collateral when obtained, clearly attributing the source.] (Use direct quotes sparingly for refusals, safety statements, or motivational anchors. Omit this section entirely if no subjective or collateral information was obtained.)

Objective

(Emphasize interval changes rather than exhaustive normal findings.)

• Appearance/Behavior: [Appearance and behavior, noting changes from prior]
• Speech: [Speech characteristics] (Include only if clinically relevant.)
• Mood/Affect: [Observed mood and affect, congruence, and range]
• Thought Process/Content: [Thought process and content] (Note SI/HI, delusions, or perseveration if observed.)
• Cognition: [Attention, memory, orientation, processing speed, executive functions] (Include only if clinically pertinent.)
• Insight/Judgment: [Insight and judgment]
• In-Session Engagement: [Effort, tolerance, redirection needs, endurance]

Interventions & Response

• Interventions: [Interventions delivered with brief description of content and link to therapy participation or rehab goals]
• Patient Response: [Observed response, participation level, and progress since last contact] (Include barriers or setbacks with plausible explanation.)
• Behavior Plan: [Adherence update, behavioral events, planned modifications] (Only include if a behavior plan is active.)

Assessment

[Clinical formulation linking psychological and behavioral factors to functional participation, rehab outcomes, and discharge risk]

• Active Diagnoses: [List active diagnoses]
• Safety Summary: [Risk level and mitigation plan if assessed; brief attestation if not clinically indicated]
• Medical Necessity: [Why psychology services are required in the IRF setting now and why ongoing frequency is justified]

Plan

• Follow-Up: [Planned frequency and focus for next session]
• Patient Practice: [Skills or strategies to use during therapies and between sessions]
• Team/Nursing Recommendations: [Cueing, reinforcement strategies, scheduling considerations]
• Family Involvement: [Planned education, coaching, or meetings] (Only include if applicable.)
• Referrals: [Referrals placed or recommended] (Only include if applicable.)
• Discharge Readiness: [Psychological readiness, safety plan, supports or limitations affecting discharge destination, follow-up needs]
• Team Communication: [Who was contacted and what was shared or recommended] (Only include if communication occurred.)

Electronic Signature: [Clinician name, degree, license] [Date/time signed]

Co-Signature: [Supervising clinician name, degree, license] [Date/time signed] (Only include if trainee documentation requiring co-signature)