Pool Safety Screening Note (Aquatic Therapy)

Patient Name: [Patient full name]
DOB: [Date of birth]
MRN: [Medical record number]
Date/Time: [Encounter date and time]
Location (facility and pool site): [Facility name and specific pool site]
Clinician: [Clinician name and role]
Encounter Type: [Aquatic Safety Screen / other]
Referral Source: [Referring clinician or service]
Primary Diagnosis/Problem: [Primary reason for rehabilitation]
History Provided By: [patient / caregiver / chart review / combination]

Reason for Screen / Planned Aquatic Program

[Functional or rehabilitation rationale for aquatic therapy]

Planned exposure parameters: [Anticipated water depth range] | [Water temperature category if relevant] | [group / 1:1 setting] | [Expected session duration and intensity] | [Therapist position: in-water / deck-based] (If parameters are not finalized, note that they will be confirmed prior to first pool entry.)

Aquatic Contraindications/Precautions Screen

(Use explicit responses for each item: [Yes / No / Unknown / Not assessed]. Do not infer "No" from silence. When any item is positive, add brief relevant details. If Unknown or Not assessed, state how information will be obtained and whether clearance is deferred.)

Cardiopulmonary

• Chest pain or pressure with exertion or at rest: [Yes / No / Unknown / Not assessed] (If Yes: [onset, severity, triggers, specialist follow-up status, baseline functional tolerance, medical clearance required before pool entry: Yes/No])
• Syncope or near-syncope history: [Yes / No / Unknown / Not assessed] (If Yes: [frequency, last event date, context/triggers, workup status, clearance needed: Yes/No])
• Dyspnea at rest or orthopnea: [Yes / No / Unknown / Not assessed] (If Yes: [severity, positional symptoms, baseline tolerance, clearance needed: Yes/No])
• Known heart failure or cardiomyopathy: [Yes / No / Unknown / Not assessed] (If Yes: [NYHA class if known, current status, specialist follow-up, clearance needed: Yes/No])
• Uncontrolled arrhythmia symptoms: [Yes / No / Unknown / Not assessed] (If Yes: [type if known, frequency, current management, clearance needed: Yes/No])
• Uncontrolled hypertension or recent markedly elevated readings: [Yes / No / Unknown / Not assessed] (If Yes: [recent readings, medication adherence, deferral threshold, clearance needed: Yes/No])
• Oxygen requirement: [Yes / No / Unknown / Not assessed] (If Yes: [baseline flow rate, target SpO2, portable system feasibility near pool, submersion limitations])
• Recent acute illness or fever: [Yes / No / Unknown / Not assessed] (If Yes: [onset, course, current symptoms, afebrile duration, deferral status])
• Other cardiopulmonary concerns: [Yes / No / Unknown / Not assessed] (If Yes: [details])

Skin/Wounds/Infection

• Open wounds or non-intact skin: [Yes / No / Unknown / Not assessed] (If Yes: [location, size, drainage characteristics, watertight coverage feasible: Yes/No])
• Surgical incisions not fully closed: [Yes / No / Unknown / Not assessed] (If Yes: [procedure date, surgeon restrictions, closure status, coverage feasibility])
• Drainage or lesions that cannot be kept watertight: [Yes / No / Unknown / Not assessed] (If Yes: [details and plan])
• Active skin infection: [Yes / No / Unknown / Not assessed] (If Yes: [diagnosis if known, treatment status, deferral status])
• Recent diarrhea or current GI illness: [Yes / No / Unknown / Not assessed] (If Yes: [start/stop dates, etiology if known, required symptom-free interval met: Yes/No/Unknown]) (For suspected or confirmed infectious diarrhea such as Cryptosporidium, a 2-week symptom-free interval is required per CDC guidance.)
• Immunocompromised status: [Yes / No / Unknown / Not assessed] (If Yes: [condition or therapy, infection control precautions])

Neurologic/Seizure

• Seizure disorder history: [Yes / No / Unknown / Not assessed] (If Yes: [seizure type, typical duration, warning aura, date of last seizure, usual frequency, known triggers, rescue medication details including what/where stored/who administers/when to activate EMS, required supervision level])
• Sudden loss of consciousness of unclear cause: [Yes / No / Unknown / Not assessed] (If Yes: [details, workup status, clearance needed: Yes/No])
• Cognitive impairment affecting safety command-following: [Yes / No / Unknown / Not assessed] (If Yes: [specific safety limitations, communication strategies, supervision level])
• Significant impulsivity or wandering risk: [Yes / No / Unknown / Not assessed] (If Yes: [mitigation steps, supervision level])

Continence

• Bowel incontinence: [Yes / No / Unknown / Not assessed] (If Yes: [predictability, containment method, ability to exit quickly, deferral due to uncontained stool: Yes/No])
• Urinary incontinence: [Yes / No / Unknown / Not assessed] (If Yes: [predictability, containment method, hygiene plan])
• Ostomy: [Yes / No / Unknown / Not assessed] (If Yes: [type, appliance integrity, watertight status])
• Indwelling or external urinary devices: [Yes / No / Unknown / Not assessed] (If Yes: [device type, submersion allowed: Yes/No, protection plan])

Mobility/Transfers/Water Entry

• Transfer assistance needs: [Yes / No / Unknown / Not assessed] (If Yes: [level of assistance, planned entry/exit method: stairs with rails / zero-depth entry / chair lift / mechanical lift])
• Assistive device use: [Yes / No / Unknown / Not assessed] (If Yes: [device, deck traction/footwear plan])
• Fall history in last 6–12 months: [Yes / No / Unknown / Not assessed] (If Yes: [number of falls, injuries, risk mitigation plan])
• Orthostatic symptoms: [Yes / No / Unknown / Not assessed] (If Yes: [triggers, management, monitoring plan])
• Fear of water or panic: [Yes / No / Unknown / Not assessed] (If Yes: [specific triggers, desensitization plan, supervision/positioning])

Thermoregulation/Devices (Include when applicable)

• Conditions affecting temperature regulation: [Present / Absent / Unknown / Not assessed] (If Present: [condition such as SCI, MS, dysautonomia, frailty, or diabetes with hypoglycemia risk; temperature precautions; intensity limits; monitoring plan])
• Implanted or external devices: [Present / Absent / Unknown / Not assessed] (If Present: [device list such as tracheostomy, central line, wound vac, implanted pump, hearing aids, CGM, insulin pump; submersion allowed: Yes/No; protection method; restriction source])

Objective Findings

• Resting vitals: HR [value] bpm | BP [value] mmHg | RR [value]/min | SpO2 [value]% [on room air / on oxygen at flow rate] (If not obtained: [reason and alternate risk control such as deferring pool entry until vitals available])
• Baseline dyspnea/exertion rating: [Scale used and value]
• Mobility relevant to pool entry: [Sit-to-stand assistance level] | [Gait stability] | [Ability to step onto curb or step] | [Ability to follow safety commands]
• Targeted skin check: [Areas inspected and findings] (Include when indicated based on screening)
• Glucose: [Value, time, pre/post timing] (Include if part of diabetes monitoring plan)

Risk Stratification & Clearance Determination

Key risks identified: [Summary of risks and relevance to water exposure]

Contraindications: Absolute: [list or None] | Relative: [list with mitigation steps, or None]

Clearance determination: [Cleared for aquatic therapy as planned / Cleared with precautions or modifications / Not cleared today / Deferred pending additional information]

Rationale: [Narrative connecting screening findings to clearance decision]

Required modifications: [Specific modifications, precautions, and monitoring] (Include if cleared with modifications)

Information needed if deferred: [What is needed] | [Who will obtain] | [Expected timeframe] (Include if deferred)

Supervision Plan & Safety Controls

• Setting: [1:1 / group] | Lifeguard present: [Yes / No] | Designated responsible clinician: [Name and role]
• Supervision level: [Direct 1:1 within immediate assist range / Close supervision with continuous visual contact / Standard per facility policy]
• Therapist position: [In-water / Deck-based] | Rationale: [Brief rationale]
• Flotation/assist devices required: [Device list with sizes/settings, or None]
• Entry/exit method: [Stairs with rails / Zero-depth entry / Chair lift / Mechanical lift] | Staff assistance: [Who assists, number of staff]
• Deck safety: [Footwear plan] | [Gait belt use: Yes/No]
• Exit/escalation triggers requiring session stop, pool exit, or emergency activation:
  • Chest pain or pressure
  • Severe dyspnea or respiratory distress
  • Syncope or near-syncope
  • Seizure activity
  • Bleeding or wound dressing failure
  • Fecal accident or suspected contamination
  • SpO2 below [specified threshold]%
  • Acute confusion, panic, or inability to follow safety commands
  • Any clinician judgment of unsafe status
  • [Other patient-specific triggers]

Emergency Plan Considerations

• Emergency response activation: [Method to call for help or alert]
• AED location: [Verified and location / Per facility policy / Unknown]
• Rescue equipment available: [Equipment relevant to patient]
• Emergency contact: [Verified: Yes/No] | [Name, relationship, phone]
• Relevant allergies: [List or None]
• Key medications accessible during session: [Inhaler / Nitroglycerin / Rescue seizure medication / Rapid glucose / Other, or None required]
• Condition-specific emergency plans: [Seizure in water response / Hypoglycemia management / Bronchospasm response / Autonomic dysreflexia response / Other] (Include when applicable to patient)

Patient/Caregiver Education & Consent

• Hygiene rules reviewed: No pool entry with diarrhea | Shower/rinse expectations | Wound coverage requirements
• Safety rules reviewed: No breath-holding contests | No swimming alone | Immediate help-seeking for symptoms | Follow staff instructions
• Expected sensations and warning signs reviewed: [What to expect] | [Signs requiring immediate exit]
• Understanding and agreement: Patient/caregiver demonstrates understanding of aquatic-specific risks and precautions and agrees to supervision and emergency plan: [Yes / No] (If No: [clarifications needed or plan])
• Refusal of key safety controls: [Yes / No] (If Yes: [controls refused, counseling provided, resulting determination])

Orders/Clearances/Follow-Up

(Include this section when participation is deferred pending medical clearance or when restrictions require confirmation.)

• Medical clearance or restriction confirmation needed: [Yes / No] (If Yes: [specific question to be answered])
• Responsible party and timeline: [Who will contact whom] | [By when]
• Aquatic therapy status until clearance: [On hold / Proceed with limited activities / Proceed as planned]
• Follow-up plan: [How and when results will be reviewed and documented]

Signature

Clinician Signature: [Signature or electronic authentication]
Credentials: [Credentials]
Date/Time: [Signing date and time]