Music Therapy Discharge Summary

Patient Name: [Patient name]

MRN/DOB: [MRN] | [DOB]

Location/Setting: [Inpatient unit / Outpatient clinic / School-based / Hospice/palliative / Community]

Episode Type: [Inpatient consult / Outpatient / School-based / Hospice/palliative / Community]

Episode Dates: [Start date] – [End date]

Total Visits: [Number scheduled] scheduled / [Number completed] completed (Include missed visits only if clinically relevant)

Session Frequency/Duration: [Typical frequency] | [Typical duration in minutes]

Author: [Name], [Credentials], [Role/Title]

Date Authored: [Date]

Cosigning Clinician: [Name, credentials, role] (Include only if required by facility policy)

Referral and Presenting Needs

(Document in 2–4 sentences or bullets. Frame needs in patient-centered, functional terms.)

• Referral source: [Referring provider and services requested] (If programmatically assigned, write "Program enrollment criteria met" with brief rationale)
• Primary needs addressed: [Coping / anxiety management / communication support / procedural support / engagement in care / symptom regulation / other functional needs]

Baseline Summary

(Summarize status at episode initiation. If no formal baseline assessment, state "Baseline not formally assessed" and summarize initial session observations. Use "Not assessed" with brief reason when applicable.)

• Physiological/symptom-related: [Pain, dyspnea, agitation, sleep, nausea, vital tolerance, other symptoms]
• Affective/emotional: [Mood, anxiety, distress tolerance, coping]
• Communicative: [Expressive/receptive abilities, AAC use, vocal output, pragmatics]
• Social-emotional: [Engagement with caregivers/staff, interaction style, play/leisure participation]
• Sensory/regulation: [Arousal modulation, sensory sensitivities, regulation strategies]
• Music-related profile: [Preferences, strengths, cultural considerations, contraindications/triggers] (Include if relevant)

Goals

(For single-session consults, document 1–2 target outcomes rather than formal goals. Note any goals added, modified, or retired during the episode with brief rationale.)

Goal (patient-centered)	Measure	Baseline	Discharge Status	Comments
[Goal statement]	[Scale / behavior count / cueing level / participation duration / self-report]	[Baseline value]	[Met / Partially met / Not met / Unable to assess]	[Brief interpretation]
[Goal statement]	[Measure/criterion]	[Baseline value]	[Met / Partially met / Not met / Unable to assess]	[Brief interpretation]

Course of Music Therapy Services

(Provide a 4–8 sentence synopsis covering: referral reason, therapy focus over time, attendance patterns, key turning points, and overall response. Note barriers and clinically relevant events without implying causation unless explicitly supported.)

[Narrative summary of course of care]

Interventions Provided

(Summarize interventions with brief rationale and typical response. Include instruments used, adaptations, and repertoire by genre or song title—do not reproduce copyrighted lyrics. Document tolerance and any adverse responses with mitigation steps. Include only intervention categories that apply.)

• Receptive: [Music listening, entrainment, relaxation—details, rationale, response, adaptations]
• Active music making: [Singing, instrument play, improvisation—details, rationale, response, adaptations]
• Compositional: [Songwriting, lyric substitution—details, rationale, response, products created]
• Verbal processing: [Lyric analysis, meaning-making—focus areas, methods, response]
• Functional/rehab-oriented: [Rhythmic cueing, breath pacing—targets, methods, cueing level, response]
• Caregiver/family interventions: [Co-treatment, education, support—details, observed responses] (Include if applicable)

Recordings/Creative Products: [Consent status, scope of use/sharing, storage location] (Include if applicable)

Outcomes and Functional Status at Discharge

Goal-by-Goal Outcomes

(For each goal, document discharge status with objective evidence, cueing/assistance level changes, participation changes, and clearly attributed patient/caregiver reports.)

• Goal 1: [Goal statement] — Status: [Met / Partially met / Not met / Unable to assess] — Evidence: [Measures, observations, cueing level changes, self-report quotes with attribution]
• Goal 2: [Goal statement] — Status: [Met / Partially met / Not met / Unable to assess] — Evidence: [Measures, observations, cueing level changes, self-report quotes with attribution]

Functional Status at Discharge

(Use "Not assessed" with brief reason when applicable.)

• Physiological/symptom status: [Findings]
• Affective/emotional status: [Findings]
• Sensory/regulation status: [Findings]
• Communicative status: [Findings]
• Social-emotional status: [Findings]
• Cognitive status: [Findings] (Include if relevant)

Integrated outcomes statement: [Brief summary integrating symptom management, participation, communication/engagement, and caregiver outcomes as applicable]

Discharge Details

Discharge Date: [Date]

Disposition: [Discharged from facility / Transferred / Outpatient episode ended / Services paused with planned reevaluation]

Reason for Discharge: [Goals met / Maximum benefit reached / No longer clinically appropriate / Patient or caregiver declined / Scheduling barriers / Program completion / Transfer to another provider] — [One-line explanation]

Closure process: [Summary review with patient/caregiver / Transition ritual / Coping plan / Not applicable]

Education and Carryover Plan

(Include only if education or home programming was provided; otherwise omit this section.)

• Content taught: [Relaxation routine / Playlist guidance / Cueing strategies / Device setup]
• Method: [Verbal / Written materials / Demonstration / Teach-back]
• Learner(s): [Patient / Caregiver / Staff]
• Learner response: [Understanding demonstrated, independent return demonstration, needs further training]
• Safety guidance: [Volume limits, session length recommendations, signs of overstimulation, trauma triggers and mitigation]

Recommendations and Follow-Up

• Music therapy recommendation: [Continue in specified setting at recommended frequency focusing on specific areas] or [Discontinue at this time with conditions for re-referral]
• Interdisciplinary referrals: [Mental health / Child life / Chaplaincy / PT / OT / SLP / Social work] for [specific needs] (Include if applicable)
• Follow-up: [Scheduled appointment or recommended timeframe for reassessment]

Care Coordination

(Include when applicable; omit if not applicable.)

• Summary shared with: [Care team / Referring provider / Outpatient contact / School team / Hospice team]
• Communication method: [EHR message / Verbal handoff / Printed summary / Secure email]
• Pending needs: [Authorizations / Equipment / Community resources / Scheduling follow-up]

(Global guidance: Maintain objective, behaviorally anchored language. Distinguish observed behaviors from patient/caregiver reports and measured data. Do not speculate about causation unless directly reported. Avoid unnecessary identification of third parties.)