Recreational Therapy Initial Evaluation

Date of Service: [date]

Time (start/stop or total): [start–stop times / total minutes]

Setting: [IRF / acute care / SNF / outpatient / behavioral health / other]

Therapist: [name, credentials]

Order on File: [Yes / No / Not required by setting]

Interpreter Used: [No / Yes — language: [specify]]

Reason for Referral

Referred by [referral source] for [stated reason]. This presents as [participation-oriented impact on leisure engagement, community access, or social interaction]. [Why now: admission, new injury or illness, functional decline, or transition of care]. Patient states: "[patient-stated priority or goal]." (2–5 sentences total; frame in participation-oriented language.)

Sources of Information

• [Patient interview] (Note qualifiers if limited by cognition, communication, or distress.)
• [Caregiver/family interview]
• [Chart review and team notes]
• [Direct observation during activity]
• Reliability: [good / moderate / limited] (State reason if limited.)

Relevant Clinical Background

(Include only information that directly impacts RT/TR service delivery.)

• [Primary diagnosis and onset date]
• [Comorbidities affecting leisure participation or safety]
• [Current precautions: weight-bearing, isolation, seizure, behavioral, other]
• [Mobility status and device use]
• [Cognitive-communication status relevant to group participation]
• [Sensory deficits impacting activity access]

Baseline Leisure Profile

Prior Leisure Lifestyle: [Pre-morbid leisure patterns, typical activities and frequency, settings, companions, meaningful roles, community involvement, transportation access]

Current Leisure Participation: [Current activities since onset/admission, comparison to baseline, initiation barriers, participation patterns such as avoidance, isolation, dependence, or overexertion]

Interests, Values, and Meaning: [Top 3 meaningful activities], [values-based motivators], [cultural considerations], [openness to adapted or novel activities]

Skills and Self-Efficacy: [Leisure skill strengths], [learning preferences], [confidence level for return to activities]

Triggers and Aversions: [Strong dislikes], [trauma or sensory triggers], [overstimulation sensitivities], [behavioral triggers impacting activity selection] (Omit if none identified.)

(If leisure history cannot be fully obtained, document what was gathered, barrier to completion, and plan to complete.)

Functional Assessment (Participation-Focused)

(Document observed performance tied to participation implications. Include only domains assessed and relevant; omit others entirely.)

Physical Function

• Activity tolerance: [minutes engaged, break frequency, symptom response]
• Balance and fall-risk behaviors: [observed behaviors, assist level, implications for groups/outings]
• Upper extremity function: [grasp, reach, dexterity relevant to activity, adaptations needed]
• Pain or symptoms during participation: [pattern, impact, management strategies]
• Adaptive equipment needs: [devices or setups to enable access]

Cognitive Function

• Attention: [sustained/divided during activity, cueing required, impact on safety/participation]
• Memory: [immediate/working/recall as observed, strategies that helped]
• Executive function: [initiation, sequencing, problem-solving, safety awareness, cueing level]
• Direction following: [1-step / 2-step / multi-step], [supports needed]

Communication and Social Function

• Communication: [expressive/receptive barriers, preferred supports]
• Group participation feasibility: [tolerated group size/duration, approach vs avoidance]
• Pragmatics: [initiation, turn-taking, boundaries, prompting level]

Emotional/Behavioral Function

• Affect and mood observed: [description, consistency with context, engagement impact]
• Coping style and frustration tolerance: [observed strategies, response to challenges]
• Anxiety/overstimulation patterns: [triggers, signs, effective modulation strategies]
• Behavioral considerations: [redirection needs, safety concerns for groups/outings]

Environmental Barriers and Facilitators

Barriers:

• [Physical access/architectural barriers]
• [Transportation limitations]
• [Financial constraints]
• [Equipment or technology needs]
• [Social isolation/caregiver availability gaps]
• [Program eligibility or access barriers]

Facilitators:

• [Accessible venues and programs]
• [Family/peer supports]
• [Existing community connections]
• [Financial resources/benefits]
• [Available adaptive equipment or technology]

Strengths and Protective Factors

• Internal: [motivation, values, identity anchors, coping skills, interests]
• External: [family engagement, peer/community ties, accessible resources]
• Clinical: [insight, learning capacity, engagement patterns, carryover potential]

Standardized Assessments

[No standardized measures administered; baseline established via structured interview and direct observation. / Assessment deferred due to [reason]; plan to administer [measure] by [date]. / Standardized measures administered as below:]

Measure	Date	Score	Participation-Relevant Interpretation
[measure name]	[date]	[score]	[interpretation tied to leisure participation]

(Include table only if measures were administered.)

Clinical Impression

[Synthesis linking impairments → activity limitations → participation restrictions], highlighting [key barriers] and [key strengths/facilitators]. Skilled RT/TR is indicated due to [specific clinical needs versus general diversion]. Patient-centered direction: [what matters most to the patient and how RT/TR will address it].

Problem List:

• [Participation-focused problem statement with underlying cause]
• [Participation-focused problem statement with underlying cause]

Goals

(SMART format with measurable criteria. Group by problem area.)

[Problem Area]

• STG: [Short-term goal: specific behavior/skill, condition, measurable criterion, timeframe]
• LTG: [Long-term episode-level participation outcome with independence/safety criterion]

[Problem Area]

• STG: [Short-term goal]
• LTG: [Long-term goal]

(Add or remove problem areas as clinically appropriate.)

Plan of Care

Service Delivery: [Individual / Group / Combination]; [frequency] x/week for [duration or episode length]

Intervention Focus:

• [Leisure education and planning]
• [Adaptive recreation training and equipment trials]
• [Community reintegration practice]
• [Coping/stress management through meaningful activity]
• [Functional skill carryover via valued activities]
• [Social skills and group participation training]

(Include only interventions relevant to identified problems.)

Precautions and Risk Management: [Supervision level, contraindications, stop rules, staffing needs for outings]

Interdisciplinary Coordination: [Key updates to team, requests from other disciplines, shared goals]

Recommendations and Discharge Planning

• [Adaptive equipment and technology recommendations]
• [Community resource referrals: inclusive recreation programs, peer groups, transportation]
• [Referrals to other disciplines if indicated]
• [Anticipated discharge leisure needs and supports]
• [Follow-up recommendations]

Signature

[Electronic signature], [credentials], [date/time]

(Attribute secondary data to source, e.g., "per PT note." Use direct patient quotes for preferences and goals. Document observable behaviors rather than diagnostic labels unless within scope.)