Recreational Therapy Plan of Care

Plan Type: [Initial RT Plan of Care / Updated RT Plan of Care]

Patient: [Patient full name] — [MRN / Encounter ID]

Date/Time: [Authorship date and time]

Author: [Author name, credentials (e.g., CTRS), department]

Location/Program: [Unit / Program / Level of Care]

Assessment Reference: [Date and location of RT evaluation informing this plan] (If unavailable, state: "Provisional pending assessment review.")

(Use patient-centered, non-judgmental language. Maintain internal consistency across problems, goals, interventions, and service parameters. Do not infer diagnosis, legal status, precautions, or medical clearance for community activities.)

Reason for Plan

[Summary of indications for RT services, current functional and participation needs, general treatment direction, and patient engagement/readiness] (Write 3–5 sentences. Do not restate the full assessment or unrelated medical history.)

RT Problem List

(List each problem as a separate entry in order of clinical priority and impact on discharge/participation goals.)

Problem 1: [RT domain label, e.g., Impaired coping/stress management]

[Functional or participation impact in patient's daily life and treatment setting]

• Baseline status: [Objective baseline with frequency, assist level, duration tolerated, standardized tool scores if used] (If baseline not yet established, state explicitly and include an objective to establish it.)
• Contributing factors/barriers: [Symptoms, environmental barriers, access issues, knowledge gaps, motivation, insight]
• Strengths/supports: [Interests, preserved skills, intrinsic motivation, family/caregiver support, community resources]
• Risk considerations: [Safety-relevant factors for this problem, e.g., behavioral escalation triggers, fall risk during activity] (Omit if none.)

Problem 2: [RT domain label]

[Functional or participation impact]

• Baseline status: [Objective baseline or note if not yet established]
• Contributing factors/barriers: [Barriers]
• Strengths/supports: [Supports]
• Risk considerations: [Safety-relevant factors] (Omit if none.)

(Add additional problem entries as needed.)

Goals & Objectives

(Organize goals by problem. Each goal must include: observable behavior, conditions, assist level when relevant, performance criterion, and timeframe. Number consistently: LTG 1 with STO 1a, 1b; LTG 2 with STO 2a, etc. Write in patient-understandable language.)

Goals for Problem 1: [Problem label]

LTG 1: Within [timeframe], patient will [observable behavior/skill] in [conditions: setting, supports, individual vs group] with [assist level], [criterion for success: frequency/duration/accuracy/scale target].

• STO 1a: By [timeframe], patient will [observable behavior/skill] in [conditions] with [assist level], [criterion].
• STO 1b: By [timeframe], patient will [observable behavior/skill] in [conditions] with [assist level], [criterion].

Goals for Problem 2: [Problem label]

LTG 2: Within [timeframe], patient will [observable behavior/skill] in [conditions] with [assist level], [criterion for success].

• STO 2a: By [timeframe], patient will [observable behavior/skill] in [conditions] with [assist level], [criterion].
• STO 2b: By [timeframe], patient will [observable behavior/skill] in [conditions] with [assist level], [criterion].

(Add additional LTGs/STOs as appropriate. If baseline is not established, include an initial STO to establish baseline.)

Intervention Plan

(Organize interventions by problem/goal. Specify mode, category, linkage to objectives, and grading strategies. For groups, include type and participation requirements. Omit modes not used.)

Interventions for Problem 1 / LTG 1

• Mode: [individual / group / co-treatment / family training / community-based]; Category: [skill development / behavioral activation / cognitive strategies / adapted physical activity / leisure education / community resource identification / activity adaptation / patient education]; Objective linkage: [STO numbers]; Methods/Activities: [Activities, tools, or curricula]; Grading/Modification: [Simplification, cueing approach, progression plan]; Participation supports: [Cues, prompts, equipment, environmental setup]
• Group details (if applicable): [Group type/theme]; [Participation requirements and supports]

Interventions for Problem 2 / LTG 2

• Mode: [Mode]; Category: [Category]; Objective linkage: [STO numbers]; Methods/Activities: [Description]; Grading/Modification: [Plan]; Participation supports: [Supports]

Service Parameters

Frequency: [Sessions per week]

Session Duration: [Minutes or range]

Plan Duration: [through discharge / specific interval / certification interval / review date] (If length of stay is unknown, specify a review date rather than estimating discharge.)

Review/Update Triggers: [Goal achievement, plateau, change in status, safety concern, discharge planning milestone]

Precautions & Safety

(Never infer precautions. If a safety-relevant precaution is unknown, state "Unknown—verify before [activity type]" and constrain plan accordingly.)

• Medical: [Fall risk, weight-bearing restrictions, seizure precautions, lines/tubes, isolation status]
• Behavioral: [Elopement risk, agitation triggers, self-harm considerations affecting group access or materials]
• Cognitive/Communication: [Simplified instructions, interpreter needs, visual supports]
• Environmental: [Unit restrictions, supervision level, off-unit privileges]

(If no precautions apply, state: "No activity precautions identified." Do not omit this section.)

Interdisciplinary Coordination

[How RT goals align with interdisciplinary treatment plan, disciplines contacted, what was confirmed or coordinated, and next steps] (If IDT plan is not available, note this and include a follow-up task to reconcile within a specified timeframe.)

Patient Education & Engagement

• Education provided: [Purpose of RT, group expectations, coping tools, leisure planning, community resources]
• Understanding/agreement: [Patient understanding and agreement or refusals with reasons if stated]
• Preferences/motivation: [Stated interests, values, recovery goals] (Include brief quotes only when clarifying.)
• Family/caregiver involvement: [Participants, topics covered, support plans] (Include only if applicable.)

Plan Update Summary

(Include this section only for Updated RT Plans of Care; omit entirely for initial plans.)

• Changes made: [Goals, precautions, frequency, interventions, or service parameters changed]
• Rationale: [Goal met, plateau, new condition, patient preference, safety issue]
• Effective date: [Date change takes effect]
• Discontinued: [Interventions or goals discontinued]
• Replacements/New: [New or revised interventions/goals]

Signature

Author Signature: [Name, credentials, date/time]

Co-Signature: [Supervising CTRS name, credentials, date/time] (Include only if authored by RT assistant or student under supervision.)