Neurologic Music Therapy Session Note (RAS, PSE, or TIMP)

Date of Service: [Date]

Setting/Location: [Location]

Therapist: [Name, credentials]

Diagnosis/Rehab Reason: [Primary diagnosis or rehabilitation reason]

Precautions: [Weight-bearing status, fall risk, hearing needs, lines/tubes, other safety notes as relevant]

Subjective

[Patient-reported goals, symptoms affecting performance, falls/dizziness since last visit, carryover of prior strategies, notable quotes] (Use direct quotes for meaningful statements. If no subjective obtained, write "Not obtained: [reason]" or omit section per local policy.)

Objective

Setup: [Assist level: independent / standby assist / contact guard / min A / mod A / max A / dependent], [equipment/devices], [positioning], [hearing accommodations] (Include only items applicable this session.)

Goals Addressed: [Goal ID(s) and specific target(s) for today]

Intervention: (Document only techniques used. Include sufficient parameters for reproducibility with units for all measures.)

• RAS: (Omit if not used.)
  • [Functional task targeted]
  • [Baseline cadence/tempo with units: steps/min or BPM]
  • [Cue form: metronome / live instrument / recorded cue / other]
  • [Training tempo(s) in BPM; progression strategy and rationale for adjustments]
  • [Dosage: bouts, duration, repetitions, rest breaks]
  • [Measured outcomes: cadence, timing accuracy, symmetry, distance, assistance level, safety observations as relevant]
• PSE: (Omit if not used.)
  • [Functional movement(s) targeted]
  • [Cue mapping: temporal / spatial / force—describe mapping of musical elements to movement]
  • [Cue form: verbal / instrumental / recorded / tactile / other]
  • [Tempo in BPM and/or rhythmic structure]
  • [Dosage: bouts, duration, repetitions, rest breaks]
  • [Measured outcomes: timing accuracy, movement amplitude, force control, functional observations as relevant]
• TIMP: (Omit if not used.)
  • [Functional objective]
  • [Instrument(s) selection; spatial placement and reach targets]
  • [Cueing strategies: rhythm, dynamics, sequencing]
  • [Tempo in BPM]
  • [Dosage: bouts, duration, repetitions, rest breaks]
  • [Measured outcomes: accuracy, initiation/termination timing, range, endurance, task transfer as relevant]
• Co-treatment: [Discipline(s)], [rationale], [role delineation] (Omit if not applicable.)

Assessment

[Overall response and tolerance] (Provide goal-oriented interpretation referencing each goal addressed.)

• [Goal ID]: [Progress: improved / stable / worsened] — [Key supporting outcomes; clinical reasoning for parameter selections and adjustments; barriers and safety concerns]
• (Repeat for each goal addressed.)

[Carryover and generalization expectations] (Note observed or anticipated transfer to functional tasks.)

Plan

• [Next session focus and technique(s): RAS / PSE / TIMP]
• [Planned parameter progressions: tempo adjustments, cueing hierarchy, task complexity]
• [Home program/carryover instructions with safety and setup requirements] (Include if provided.)
• [Coordination with PT/OT/SLP/team] (Include if applicable.)

Signature: [Therapist signature, credentials, date/time]

(Missing information: Use "Not assessed: [rationale]" for fields normally expected but unobtainable. Do not infer diagnosis or etiology. Attribute information to patient report, chart, or team communication.)