Re-Evaluation Note (Animal-Assisted Therapy)

Date of Service: [Date]

Location: [Setting / unit / room]

Therapy Discipline: [PT / OT / SLP / Behavioral Health]

Clinician: [Name, credentials]

Reason for Re-Evaluation: [scheduled interval / change in status / failure to progress / pre-discharge / new findings]

Animal-Assisted Modality Status: [used / attempted but deferred / not used this episode]

Re-Evaluation Context

[Condition(s) being treated and functional focus]. Initial evaluation: [date]. Last progress report or re-evaluation: [date]. [Explicit reason re-evaluation is indicated now]. [Animal-assisted intervention type if applicable: goal-directed animal-assisted therapy / informal animal-assisted activity]. (Keep to 2–4 sentences. Complete this note type only when a formal re-evaluation trigger is present.)

Subjective

[Patient/caregiver report of functional change since last assessment, including relevant symptoms impacting function. Patient perspective on animal-assisted component with direct quotes for strong preferences, fears, or perceived benefit. Adverse events or concerns related to animal exposure if any.] (Use 1 short paragraph or 2–4 bullets. If patient cannot report, state the reason and identify alternate data source.)

Objective

Measures:

• [Measure name] — Prior: [score, date]; Current: [score, date] (Note changes in testing conditions if applicable.)

Function:

• [Functional task/performance] — [Assist level / cues / device / safety needs] (Include distances, durations, reps, accuracy as relevant.)

AAT Observations: (Only include if animal-assisted modality was used or attempted this episode.)

• [Therapeutic tasks paired with animal involvement] — [Observable patient responses: engagement, affect, tolerance, performance metrics] (Use comparative language only when supported by documented prior observations. Do not attribute causality to animal without substantiation. If AAT was attempted but deferred, state reason and patient response.)

Goal Status

• [Goal 1]
  • Baseline: [Metric, date]
  • Current: [Metric, date]
  • Status: [Met / Partially Met / Not Met / Discontinued]
  • Decision: [Continue / Modify / Discharge]
• [Goal 2]
  • Baseline: [Metric, date]
  • Current: [Metric, date]
  • Status: [Met / Partially Met / Not Met / Discontinued]
  • Decision: [Continue / Modify / Discharge]

(Add additional goals as needed; prioritize by clinical importance. If goal not assessed, state reason and planned reassessment timeframe.)

Assessment

[Clinical interpretation integrating subjective and objective findings, including overall change since prior comparison point and progress toward goals. Statement of continued skilled need and medical necessity. Key barriers to progress.] [AAT component: appropriate to [continue / modify / discontinue]; safety concerns: [identified concerns / none].] (Limit to 1–2 short paragraphs.)

Plan

• Interventions: [Types/modalities] — [Frequency x duration] — [Progression strategy]
• AAT plan: [Therapeutic rationale tied to goals]; [Patient-specific constraints if any]; [Planned frequency of animal inclusion] (Only include if AAT to continue.)
• Safety/infection control: [Screening and precautions confirmed per facility policy] (Include when animal contact occurred.)
• Education/home program: [Content provided; materials/HEP updates; caregiver training] (Only include if provided.)
• Referrals/coordination: [Consults, team communication, care coordination] (Only include if initiated.)
• Next reporting point: [Date or event for next progress note or re-evaluation]

(If no plan changes indicated, state: Plan reviewed; no revisions recommended.)

Clinician Signature / Credentials / Date-Time Signed: [Signature block]