Palliative Care Comfort Activity Note (Recreational Therapy)

Date/Time: [Date of service; start time – end time] (Include start/end time if required by facility policy.)

Setting: [inpatient unit / home / SNF / hospice facility / other]

Author: [Name, credentials] (Include supervising clinician if applicable.)

Participants: [Patient; caregivers/family present; other staff; interpreter] (If no caregiver present, state "no caregiver present" per facility preference.)

Summary: [1–2 sentence summary of visit purpose and overall outcome] (Include primary modality used and net effect with supporting observable indicator.)

Clinical Context & Baseline

Reason for RT visit: [Consult request / routine comfort visit / response to acute distress / family request / other] (State source of request.)

Patient-centered goal(s) from plan of care: [Reduce anxiety / promote calm / support meaningful connection / legacy work / other] (If plan-of-care goals not available, state that intervention was selected based on patient/caregiver stated priorities.)

Preferences & considerations: [Music genre/artist; sensory preferences/aversions; cultural considerations; acceptable touch boundaries] (Include only items explicitly identified.)

Pre-intervention status: [Patient/caregiver report of comfort concerns or session goals]; [Clinician observations of appearance, affect, restlessness, grimacing, respiratory pattern, engagement level, environmental factors]

Baseline symptom rating(s): [Symptom domain(s) and rating(s) on 0–10 scale or facility tool] (If patient cannot rate, document observable indicators and source.)

Consent/capacity: [Patient consent/assent obtained / unable to consent due to diminished capacity] (If unable to consent, document basis for proceeding and safeguards used.)

Intervention

Type(s): [sensory comfort/modulation / music-based activity / relaxation or guided comfort / legacy or reminiscence]

Delivery details: [Live vs recorded; device/method; genre/selection; sensory items used; touch modality if within scope]

Duration: [Total minutes engaged] (Note if divided into segments.)

Adaptations: [Adjustments for fatigue, delirium, dyspnea, pain, cognitive or sensory limitations] (Include pacing, positioning, cueing, or low-stimulation modifications.)

Clinical reasoning: [Rationale for selected approach]

Legacy/reminiscence specifics: [What was created; consent documented; storage location; recipient(s) of copies] (Include only if legacy work performed.)

Response & Tolerance

Participation level: [active / prompted / passive-receiving / declined]

Tolerance: [tolerated well / needed breaks / stopped early / declined] (State reason if stopped early.)

Adverse responses: [none / increased agitation / overstimulation / emotional distress / other] (If present, document action taken.)

Post-intervention observations: [Changes in breathing, restlessness, grimacing, facial expression, engagement, verbal/nonverbal relaxation cues]

Post-intervention symptom rating(s): [Symptom domain(s) and rating(s) on 0–10 scale or facility tool] (If unable to rate, document observable indicators and source.)

Goal progress statement: [Brief linkage between response and stated goals] (Pair any documented improvement with supporting observable indicators. If no benefit observed, note the limiting barrier.)

Plan & Coordination

RT plan: [continue / modify frequency or approach / discontinue]; [next planned modality or focus]

Caregiver/family education: [Instructions for safe continuation; signs of overstimulation; when to stop] (Omit or state "no caregiver present" per facility preference.)

Team communication: [Team member(s) notified]; [concerns or updates communicated]; [plan-of-care updates requested] (Include only if performed.)

Carryover recommendations: [Playlist access; sensory kit; relaxation script; environmental adjustments] (Include only if applicable.)

If patient declined or could not be seen: [Reason]; [alternative offered]; [reschedule plan] (Use only when applicable.)