Palliative/Hospice Music Therapy Session Note

(Omit sections or fields not relevant to this encounter; do not include placeholder labels. Ground any interpretive statements in observable evidence.)

Patient: [name / MRN]

Date of Service: [date]

Session Time: [start time – end time, total minutes]

Setting: [home hospice / inpatient palliative unit / hospice IPU / SNF/ALF / other]

Therapist: [name, credentials]

Participants: [patient participation level: active / intermittent / passive receptive / non-responsive; family/caregiver(s) present and role(s); interpreter if used]

Clinical Focus

[Primary symptom or psychosocial targets (1–3) with link to corresponding plan-of-care goal for each] (If patient unable to participate or provide input, note why and whose report informed targets.)

Subjective

[Patient chief concern in own words] (Use brief, selective direct quotes regarding symptom distress and goals for the session. For nonverbal or non-responsive patients, identify proxy source and summarize observed distress indicators instead.)

[Family/caregiver perspective] (Include only if present and clinically relevant.)

Objective

Baseline

[Patient presentation at session start: alertness, communication mode, relevant physiologic or nonverbal distress cues]

Symptom Ratings

(For each targeted symptom with a rating, use the format below. Do not fabricate estimates. If unable to rate, state why.)

• [Symptom]: [scale name]. Pre: [score] Post: [score]. Rated by: [patient / caregiver / clinician observation].

Interventions

[Modality delivered, therapeutic technique and intent, patient/family participation level] (Document in reproducible terms. Note cultural/spiritual music preferences or boundaries when relevant. For legacy work, specify artifact created or advanced and confirm consent for any recording.)

Response

[Observable changes during and after session tied to targeted symptoms] (Include physiologic/behavioral shifts, affect changes, engagement or communication outcomes, expressions of meaning or connection. Note durability of effect if known.)

Assessment

[Synthesis of baseline distress, interventions provided, key responses observed, and progress toward plan-of-care goals: progress / partial progress / no change / decline] (One concise paragraph. Include clinical reasoning for significant decisions only when relevant.)

Plan

Next Session

[Recommended focus and specific tasks]

Caregiver Guidance

[Concrete between-visit recommendations if provided] (e.g., suggested playlists, how to use music during symptom episodes, when to contact hospice team)

IDT Communication

[Team member(s) notified] — [Key information communicated: symptom changes, notable response, spiritual concerns, caregiver distress, referral recommendations]

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