Interdisciplinary Co-Treatment Note (Animal-Assisted Therapy)

Date/Time: [Date and time of session]

Patient: [Patient name or identifier]

Discipline A Provider: [Name, credentials]

Discipline B Provider: [Name, credentials]

Therapy Animal/Handler: [Animal name; handler name/organization]

Total Session Duration: [Duration in minutes]

Session Overview

[Co-treatment rationale explaining why joint delivery benefits this patient] [Shared goals addressed today in functional/measurable terms] [AAT status: used as planned / modified / deferred, with reason if not as planned] [Confirmation of AAT consent and contraindication screen completion, or specific concerns identified] (Write 3–5 concise sentences. If setting requires, include explicit statement that services were delivered simultaneously by both disciplines.)

Subjective

[Patient or caregiver report relevant to today's session: symptoms, mood, motivation, priorities, goals] (Use brief direct quotes for key statements, especially regarding animal interaction; attribute quotes to speaker.)

Objective

• Presentation: [Affect, arousal, engagement, attention, motor status] (Use observable descriptors only.)
• Environment: [Relevant environmental factors, setting, equipment, positioning, people present] (Include factors impacting participation and safety.)
• Safety-relevant data: [Allergy status, infection control steps, vitals/pain, behavior triggers, fall risk as indicated] (Only include if obtained and relevant.)
• Baseline assistance/cueing: [Starting level of assistance and cue type relevant to goals] (E.g., [independent / supervision / min / mod / max assist]; [verbal / visual / tactile] cues.)

Interventions

[Discipline A]: [Skilled actions performed to improve/address target impairment or function] (Include clinical reasoning, grading/progression, cueing strategy, adaptations, and coordination with second discipline.)

[Discipline B]: [Skilled actions performed to improve/address target impairment or function] (For behavioral health disciplines, specify techniques such as exposure, coping rehearsal, cognitive restructuring. Include grading, cueing, adaptations, and co-treatment coordination.)

Animal modality: [How the animal facilitated or graded the intervention: motivation/engagement, arousal regulation, functional task context, graded exposure] (Document supervised contact parameters, handler control, infection control steps, and any termination cues used. Describe only observable patient responses to the animal.)

Education provided: [Learner(s); content taught; method; response/return demonstration] (Omit section if none provided.)

Assessment and Plan

Assessment: [Progress toward shared goals] [Why services remain skilled/medically necessary] [Effectiveness of animal-assisted modality tied to observed outcomes] [Adverse events or safety concerns and de-escalation steps used, if any] (Synthesize co-treatment outcomes; avoid repeating Objective details.)

Plan: [Next session focus with goal linkage] [Plan for animal involvement: continue / modify / fade] [Home program or carryover recommendations] [Coordination needs with clear ownership] (Include frequency/duration updates if discussed.)

Signatures

Discipline A: [Signature, date/time, credentials]

Discipline B: [Signature, date/time, credentials]

Billing

[Timed code minutes by service and discipline; billed interventions using language comparable to CPT descriptors] (Include only if required by setting. Add co-treatment/concurrent time attribution if required by payer.)

(Do not finalize note until required elements are complete: date/time, interventions, signatures. Omit optional elements rather than leaving blank placeholders. When a data point cannot be obtained, document why. Do not infer patient internal states from animal behavior; record only observable patient responses and attribute feelings via patient quotes.)