Music Therapy Session Note (SOAP, In-Person/Telehealth)

Date: [date of service]

Time: [start time] – [end time] ([duration])

Modality: [In-person / Telehealth (video) / Telehealth (audio-only)]

Setting: [location/site]

Patient: [name, MRN or identifier]

Therapist: [name, credentials (e.g., MT-BC)]

Others Present: [caregiver, interpreter, etc.] (Omit if none)

Telehealth Details: [Platform used; connection quality and any clinical impact of technical limitations; identity verification method; patient physical location; emergency contact/backup plan if disconnected; caregiver role if facilitating] (Include only for telehealth encounters; omit for in-person)

Subjective

[Patient and/or caregiver report of current concerns or mood state; changes since last session; response to any prior home practice or between-session activities; relevant music preferences or requests; any patient-reported safety concerns] (Attribute clearly, e.g., "Patient reports…" or "Caregiver reports…" Use direct quotes sparingly for high-salience statements only. If patient cannot provide subjective information, briefly note the reason.)

Objective

Presentation: [affect; engagement; communication; observable behaviors relevant to session]

Interventions and Responses:

• Intervention: [type, e.g., receptive listening, live entrainment, improvisation, songwriting, lyric analysis, instrument play] | Goal: [targeted treatment goal] | Parameters: [duration; tempo; instruments; cueing level; structure] | Response: [observable behavioral/functional markers: engagement, tension changes, breath pacing, verbalization, participation level; notable events or adverse reactions]

(Repeat intervention entry for each distinct intervention delivered. For telehealth, note any observation limitations due to technology.)

Data: [standardized measure(s) or ratings used; pre/post values and comparison] (Omit if no measures were used)

Assessment

[Clinical interpretation of observed responses and their meaning; progress toward session goals (improving / plateauing / variable); clinical reasoning behind intervention choices or adaptations; barriers encountered (e.g., fatigue, pain, environmental factors, technology issues); brief safety/risk statement if assessed, if risk emerged, or if required by setting] (Do not introduce new patient-reported details here)

Plan

Next Session: [goals/objectives to address; planned intervention approaches; anticipated modifications to technique, tempo, cueing, or structure]

Home Practice: [specific activity; frequency/duration; safety guidance; adherence monitoring plan] (Omit if not applicable)

Coordination: [team communication, caregiver education, referrals] (Omit if not applicable)

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Therapist Signature: [electronic signature]

Credentials: [professional credentials and title]

Date/Time Signed: [date and time]