Recreational Therapy Consultation Note

Date/Time of Service: [Date and time of encounter]

Author: [Name, credentials (e.g., CTRS), role/title]

Location/Unit: [Unit / room / bed]

Contact Type: [in-person / phone / video / chart review only]

Consult Request

[Requesting service/team and requester name if known] — "[Consult question in requester's terms]" [Urgency if specified]

(If the request required clarification, document who clarified and the revised question. Omit this line if not applicable.)

Sources of Information

(Omit this section entirely if the assessment was straightforward with no collateral sources or limitations.)

• Patient interview: [yes / no] (If no, state reason)
• Collateral input: [Source and role] (Include only if used)
• Interpreter: [Language and modality] (Omit if not needed)
• Chart review: [Scope of documents reviewed]
• Assessment limitations: [e.g., delirium, fatigue, pain, time constraints, reliability concerns] (Omit if none)

Relevant Chart Review

(Include only chart elements that materially affect RT participation, safety, or intervention selection. If pertinent information was unavailable, state this explicitly rather than leaving blank.)

• Reason for admission and RT-relevant diagnoses: [Brief summary]
• Activity orders and precautions: [e.g., weight-bearing status, mobility restrictions, brace/splint requirements]
• Isolation status: [None / type and implications for group eligibility]
• Fall risk and equipment/lines: [Fall risk level; lines/tubes/devices relevant to activity safety]
• Baseline function: [Pre-hospital mobility, ADLs, cognition, leisure participation]
• Current function: [Mobility/ADLs/cognition per therapy/nursing documentation]
• Anticipated discharge setting: [home / home with support / SNF / IRF / LTACH / TBD] (Include if relevant to recommendations)

Recreational Therapy Assessment

Patient-stated goals/concerns: [Use direct quotes when meaningful; otherwise summarize priorities]

Barriers to participation: [e.g., anxiety, low motivation, boredom, social isolation, cognitive fatigue, pain, limited endurance]

Strengths and supports: [e.g., supportive family/caregivers, prior leisure interests, coping skills, personal values/roles]

Safety and Appropriateness Screen (Complete when recommending groups or mobility-based activities)

• Cognition/attention for group: [sufficient / insufficient / unclear] — [Brief supporting observations]
• Behavioral appropriateness for group: [appropriate / requires cues / not appropriate] — [Brief rationale]
• Mobility/transfer needs: [independent / supervision / assist level] — [Device or support needs]
• Communication needs: [Hearing/vision supports, aphasia strategies, interpreter requirements]
• Medical constraints: [Pain, endurance, orthostasis, vitals parameters] — [Activity implications]
• Infection control constraints: [None / type and impact on group eligibility]

Leisure and Interest Profile

• Pre-hospital activities: [Brief list of preferred activities]
• Current in-hospital interests: [Brief list]
• Identity roles supporting motivation: [e.g., parent, veteran, artist, athlete]
• Preferred social engagement: [group / 1:1 / independent] — [Tolerance for stimulation]
• Adaptive needs: [Sensory, cognitive, or physical accommodations needed]

Standardized tools: [Tool name] — [Score/result] — [Interpretation] (If considered but not completed, briefly note why. Omit if no tools used.)

(If the patient was not directly assessed, explicitly state this and note that recommendations are based on chart review only.)

Clinical Impression

[2–4 sentence synthesis: Is RT indicated and why? Key enabling and limiting factors. Group appropriateness determination with brief rationale.]

Recommendations

(Include only applicable categories. Prioritize most important first. When assessment is chart-review only, constrain to low-risk items and specify criteria for in-person reassessment.)

1. RT services and focus: [e.g., coping skills, leisure education, relaxation, socialization, community reintegration] — [Proposed frequency]. Short-term goals: [Functional, measurable goals]

2. Activity recommendations: [Bedside / room-based / 1:1 / independent activities]. Assistance level: [Supervision/assist requirements]. Equipment/adaptations: [Items needed]. Environment: [Setup considerations]

3. Group recommendations: [Specific groups and therapeutic targets]. Readiness criteria: [Cognition, behavior, mobility, isolation status requirements]. Supervision/escort: [Requirements]. Contraindications/reassessment triggers: [What change would allow participation]

4. Safety considerations: [Activity-specific fall prevention, behavioral safety, lines/tubes management]. Escalation triggers: [When to stop activity and notify nursing/medical team]

5. Coordination: [Requests to nursing for timing/transport; coordination with PT/OT/SLP; suggested referrals to primary team]

6. Follow-up plan: [When RT will reassess and what will be evaluated] OR [One-time advisory consult; criteria for re-consultation]

Communication

• Team communication: [Name, role, service] — [Method: secure message / phone / in-person] — [Date/time] — [Brief summary of discussion and any urgent safety issues conveyed]
• Patient/family communication: [Who, method, summary] (Include if relevant to team coordination)

Signature:
[Name], [Credentials] — [Role/Title]
[Department/Service]
[Contact information]