Outcome Measures Flowsheet (Yoga Therapy)

Patient: [Patient name]    DOB: [Date of birth]    MRN: [Medical record number]

Encounter Date: [Date]

Encounter Type: [in-person / video / phone]

Clinician: [Clinician name], [Credentials]

Episode Baseline Date: [Baseline date for this episode]

Measurement Set

(Keep this section stable across visits; update only when measures change. Omit domains not relevant to this patient. Do not reproduce questionnaire items; record instrument name, version, and scores only.)

Domain	Instrument	Score Range & Directionality	Meaningful Change Threshold	Administration Cadence
[Domain name]	[Instrument name and version]	[Score range]; [higher/lower] scores indicate worse status	[Threshold, e.g., 2-point change or 30% reduction]	[every visit / weekly / monthly / baseline + discharge]
[Domain name]	[Instrument name and version]	[Score range]; [higher/lower] scores indicate worse status	[Threshold]	[Cadence]

(Add or remove rows as needed. Common domains: Pain, Sleep, Depression, Anxiety, Function, Goal Attainment.)

Current Results

(If no measures were collected this visit, state: "Prior measures reviewed; none collected today" with brief reason such as declined, not due, or technical issue.)

Measure	Date Collected	Score	Change vs Baseline	Change vs Prior	Severity Band	Meaningful Change
[Instrument/domain]	[Date]	[Score]	[Numeric and/or % change]	[Numeric and/or % change]	[Severity band per instrument]	[improved / worsened / stable]
[Instrument/domain]	[Date]	[Score]	[Change vs baseline]	[Change vs prior]	[Severity band]	[improved / worsened / stable]

Patient/clinician context: (Include only if directly pertinent to interpreting scores; limit to 2–3 brief points.)

• [Brief patient context related to measures, e.g., recent sleep disruption, medication change]
• [Clinician observation relevant to scores, e.g., movement quality, affect]

Trends Over Time

(Include only when 2 or more timepoints exist. Mark missed entries as "not due," "declined," or "technical issue" rather than leaving blank. If the EHR auto-generates graphs, a concise trend statement may substitute for the table.)

Date	Collection Mode	[Measure A]	[Measure B]	[Measure C]
[Baseline date]	[self-report / clinician-administered / proxy]	[Score or reason not collected]	[Score or reason not collected]	[Score or reason not collected]
[Follow-up date]	[self-report / clinician-administered / proxy]	[Score or reason not collected]	[Score or reason not collected]	[Score or reason not collected]

(Add or remove measure columns to match the Measurement Set.)

Interpretation

(Include an entry only for domains measured today. Clearly distinguish computed elements—severity band and MCID—from clinical judgment. Do not over-interpret fluctuations within measurement noise. For screening tools, explicitly document screen positive/negative and whether confirmatory assessment is needed or completed.)

• [Domain name]: [improving / worsening / stable]; [meets / does not meet] meaningful change threshold. [Brief clinical context or confounders].
• [Domain name]: [improving / worsening / stable]; [meets / does not meet] meaningful change threshold. [Brief context].

Cross-domain synthesis: [Summary of relationships across domains and overall clinical picture; note any discordant trends and possible explanations.] (2–3 sentences; avoid duplicating data from above.)

Safety Review

(Include this section only when safety concerns are triggered—e.g., any non-zero self-harm item, severe score with functional impairment, severe/escalating pain with red flags, or patient-reported unsafe situation. Do not infer safety status from total scores alone; document explicit follow-up assessment.)

• Trigger: [Instrument, specific item, score, and date that triggered review]
• Follow-up assessment: [Presence/absence of intent and plan; protective factors identified; brief assessment findings]
• Actions taken: [crisis resources provided / referral initiated / supervising clinician notified / emergency services involved / patient declined intervention—capacity assessed and safety counseling documented]

Plan Updates Based on Measures

(Document how outcome measures influenced the yoga therapy plan. For each domain with meaningful change or clinical concern, link plan changes explicitly to measure results.)

• [Domain/Measure]: [Plan change or "no change"]. Rationale: [explicitly linked to measure result]. Patient [agrees / expressed concerns about / declines].
• Yoga therapy adjustments: [Session frequency/duration changes]; [practices emphasized or de-emphasized]; [home practice prescription changes]; [updated contraindications or precautions].
• Referrals/coordination: [If triggered by measures: provider/service, reason, and status] (Omit if none.)

Monitoring Plan

Instrument	Next Planned Administration	Method	Modifications & Rationale
[Instrument name]	[Date or visit number]	[portal pre-visit / in-session]	[Modification and rationale, or "none"]
[Instrument name]	[Date or visit number]	[portal pre-visit / in-session]	[Modification and rationale, or "none"]

Attestation

Outcome measures were reviewed this visit and incorporated into assessment and yoga therapy care planning.

Electronically signed by [Clinician name, credentials] on [Date/time].