Recreational Therapy Incident/Safety Event Note

Date/Time of Note: [Date and time of documentation] (If late entry, label per policy with actual entry time.)

Event Date/Time: [Exact time or approximate range if unwitnessed]

Author/Credentials: [Name, role, credentials]

Location: [Unit and specific area]

Witnessed Status: [witnessed / unwitnessed / patient-reported / staff-assisted to floor]

RT Service Context: [individual / group]; [activity in progress]

Others Present: [Roles present; use "peer patient" for other patients]

Event Summary and Timeline

[One-sentence plain-language summary of what occurred]

[Chronological account with time-stamped entries when times are known, e.g., "14:05 – Patient stood from chair without assistance." Use time anchors when exact times unknown, e.g., "approximately 14:10, between rounding and group start."]

(Document only directly observed or clearly attributed facts. Use concrete, observable language. Include patient statements in quotes when they clarify symptoms, intent, or perception. For unwitnessed events, state "mechanism unknown" rather than speculating.)

Assessment and Findings

[Post-event observations within RT scope: level of consciousness, reported pain location and severity, visible injuries with description and location, head strike status, mental/behavioral status compared to baseline]

[For behavioral events: observable behaviors, identified triggers, de-escalation strategies attempted with patient response]

[Elements deferred to nursing or provider, stated explicitly, e.g., "Vital signs obtained by nursing"]

(Document observable findings only. Do not diagnose causes or speculate on mechanism. Describe appearance and location of injuries without diagnostic language.)

Response and Notifications

Immediate Actions: [Actions taken: activity stopped, patient repositioned, first aid, area secured, protective actions for other participants]

Notifications: [Time and role for each notification, e.g., "14:12 – Charge RN notified; 14:15 – RT Supervisor notified"]

(Do not document completion of internal incident/safety reports in the medical record.)

Disposition and RT Plan

Disposition: [returned to unit / remained in program area / transferred for evaluation / EMS transport / other]

RT Modifications: [Supervision level changes, adaptive equipment needs, environmental adjustments, criteria for return to RT activity]

Unknown Elements: [State explicitly with reason, e.g., "Mechanism unknown; patient unable to recall"] (Omit if not applicable.)