Music Therapy Consult Note

Date/Time: [Date and time of consult]

Patient: [Full name], [MRN], [DOB]

Location: [Unit/room or telehealth location]

Referring Clinician/Service: [Name and role / Service]

Consult Modality: [in-person / telehealth / chart review only]

Participants: [Participants present and roles] (Include interpreter if used)

Reason for Consult

[Consult question and targeted clinical need(s)] (Summarize in 1–3 lines; specify target(s) such as anxiety, pain, procedural support, agitation, coping, or sleep; include any timeframe or constraints from referrer. If unclear, document that clarification was sought.)

Clinical Context

• [Current admission reason and pertinent diagnoses] (Include only details relevant to consult targets)
• [Current symptom status related to targets] (Quantify intensity, frequency, or timing if available)
• [Pertinent precautions affecting music use] (e.g., hearing status, cognitive status, respiratory support, mobility restrictions, isolation precautions)
• [Assessment limitations, if any] (e.g., sedation, language barrier, delirium, fatigue, time constraints)

Music Therapy Assessment

(Organize around consult targets. Use objective, observable terms. If consult modality is chart review only, explicitly state no direct patient assessment occurred.)

• Presenting status and readiness for music engagement: [Arousal/alertness], [Attention], [Affect], [Communication ability], [Tolerance for sensory stimulation], [Environmental constraints]
• Patient-reported ratings: [Symptom type, scale used, and value] (e.g., anxiety 6/10; include patient-stated goal in their own words if provided; omit if patient unable to report)
• Music preferences and responsiveness: [Preferred genres/artists/instruments], [Language/cultural/spiritual preferences], [Delivery preference: live vs recorded, headphones vs speaker, active vs receptive], [Known aversions or triggers], [Prior helpful experiences with music for coping]
• Functional observations tied to consult target(s): [Breathing pattern changes, visible relaxation or tension, attention span, ability to follow prompts, participation level, other target-relevant observations]

Clinical impression (music therapy perspective): [Brief rationale for why music-based strategies may help for this patient and target(s)] (Note uncertainty if based on limited trial or indirect information)

Intervention During Consult

(Include this section only if a music-based intervention was performed; omit entirely if no intervention occurred)

• Intervention type and details: [Live music / Guided music listening / Music-assisted relaxation / Lyric discussion / Other], [Duration], [Delivery method], [Patient participation level: passive / active / co-creative]
• Patient response: [Behavioral and physiologic responses observed], [Patient-reported experience], [Pre/post symptom ratings with scale used]
• Modifications: [Adjustments to tempo, volume, or content], [Elements avoided and reason], [Adverse effects, if any]

Recommendations

(Provide 3–6 specific, actionable strategies linked to assessed needs and preferences. If consult modality is chart review only, keep recommendations conservative and emphasize close monitoring.)

• Patient self-directed strategies: [What to do], [When to use], [How to implement: tempo, volume, duration], [Stop criteria]
• Staff/caregiver-supported strategies: [Simple steps staff can safely support], [Monitoring parameters], [What to avoid]
• Equipment/accessibility needs: [Device source], [Headphones or single-ear option], [Cleaning requirements], [Access to preferred content or playlists]

Precautions

(Required in all consult notes. If key safety information is unknown, state this and recommend conservative use with close monitoring.)

• Medical: [Hearing sensitivity], [Seizure considerations], [Respiratory support and positioning], [Pain or fatigue thresholds], [Other physiologic constraints]
• Behavioral/Neurocognitive: [Delirium risk or overstimulation], [Trauma-associated triggers or content to avoid], [Sensory processing considerations], [Agitation precautions]
• Infection control and equipment safety: [Device cleaning protocol], [Headphone covers or single-patient use], [Cord management around lines or tubes]
• Unknowns and monitoring: [Unknown safety factors], [Specific monitoring cues and stop criteria]

Communication to Team

• Recipient(s): [Name(s) and role(s) notified]
• Method and timing: [In-person / phone / secure message], [Date and time]
• Content of handoff: [Top recommendations reviewed], [Key precautions and stop criteria communicated]

Disposition

• Consult outcome: [One-time consult complete / Recommend ongoing music therapy]
• [If ongoing: suggested frequency and goals linked to consult targets]
• [Criteria for re-consultation or signs to discontinue strategies]
• [If patient declined: document refusal and reason if stated]

Signature

[Author name, credentials] — [Date and time signed]