Music Therapy Progress Report (Re-evaluation)

Patient Name: [Patient full name]

MRN: [Medical record number]

Date of Report: [MM/DD/YYYY]

Reporting Period: [Start date] to [end date]

Sessions This Period: [Number delivered] (Note cancellations or no-shows if relevant to progress interpretation.)

Music Therapist: [Name, credentials]

Report Type: [Progress Report / Re-evaluation]

Re-evaluation Details: [New measurement performed and rationale] (Include only if Report Type is Re-evaluation.)

Reason for Report: [Scheduled review / payer milestone / clinically indicated change / transition planning]

Service Context & Interval Summary

[Service context overview] (Briefly orient the reader to: primary reason for music therapy involvement, relevant diagnoses or conditions affecting care, current plan-of-care parameters including frequency, setting, and primary treatment domains, and any precautions. Reference where the full POC resides if applicable.)

[Interval changes summary] (Summarize patient/caregiver/staff-reported changes relevant to goals, medically relevant changes affecting the music therapy plan, and barriers to participation encountered. Include one brief direct quote if it captures the patient's subjective experience. Keep to 3–5 sentences total.)

Objective Indicators & Goal Progress

Outcome Measures:

• [Measure name] — Reporter: [Patient / caregiver / staff / therapist observation]; Baseline: [Value and date]; Prior interval: [Value and date]; Current: [Value and date]; Change: [Improved / stable / worsened / not comparable] (Include scoring anchors if non-standard. For missing data use: Not available in chart, Not collected, or UTA with reason. Repeat for each measure used.)

Goal Progress:

• Goal: [Brief goal statement]

  Status: [Met / Partially met / Progressing / Plateau / Regressing / Discontinued / Not targeted this interval]

  Evidence & Interpretation: [Link to outcome measures and session observations; include within-session pre/post changes when relevant; provide concise clinical interpretation grounded in documented data.]

  Intervention Response: [Primary approaches used, engagement/cueing level, observable indicators such as affect or initiation, modifications made, and disposition: continue / modify / discontinue with rationale.] (If goal not addressed, state reason.)

• Goal: [Brief goal statement]

  Status: [Met / Partially met / Progressing / Plateau / Regressing / Discontinued / Not targeted this interval]

  Evidence & Interpretation: [Objective support with clinical interpretation]

  Intervention Response: [Approaches, engagement, indicators, modifications, disposition]

(Repeat goal block for all active goals. Use explicit statuses for missing data: UTA with reason, Not collected, or N/A. Never leave blanks or fabricate data.)

Clinical Assessment

Overall Trajectory: [Improving / stable / fluctuating / declining] (Provide concise narrative grounded in documented observations and measures.)

Responsiveness Profile: [Conditions or contexts that predict benefit or reduced benefit]

Skilled Service Justification: [Differentiate skilled intervention from non-skilled activity; cite specific clinical decision-making, graded cueing, or safety considerations.]

Risk Considerations: [Relevant risks or precautions] (Omit if none.)

Prognosis: [Short-term outlook for goal attainment based on current trend] (Avoid new diagnoses or unverifiable causal claims.)

Updated Plan

Service Recommendation: [Continue / modify / discontinue] music therapy at [frequency] in [setting].

Goals Audit Trail:

• Met and retired: [Goals retired this interval, or "None"]
• Modified: [What changed and why] (Specify measurable components updated.)
• New goals added: [Goal with brief justification linked to data, or "None"]

Discharge/Transition Criteria: [Triggers for discharge or transition and handoff plan] (Include when discharge is foreseeable.)

Between-Session Guidance: [Home program or caregiver/staff recommendations provided] (Omit if none.)

Interdisciplinary Coordination: [Communications with care team, referrals, care conferences with dates and recipients] (Omit if none this interval.)

Signature

Therapist Signature: [Signature]

Credentials: [e.g., MT-BC, LCAT]

Date/Time: [MM/DD/YYYY HH:MM]

Supervisor Co-signature: [Signature] (Include only if required by facility or payer policy.)