Recreational Therapy Reassessment/Progress Report

Patient Name: [Patient name]

Date of Birth: [DOB]

Reporting Period: [start date] – [end date]

Date Authored: [date]

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

Level of Care/Program: [e.g., inpatient rehab / psych inpatient / SNF/LTC / outpatient]

Relevant Diagnoses: [RT-relevant medical/behavioral diagnoses] (Include only those that directly impact RT participation and goals.)

Precautions: [precautions] (Omit this line if none.)

Interval Summary

[Concise interval summary] (4–6 sentences. Include: the trigger for this reassessment [routine interval / status change / POC review / discharge planning / payer authorization / other]; overall participation trajectory [improving / stable / declining] with brief objective evidence; and any notable changes in medical, functional, or psychosocial status that affected RT participation. If interval data are limited due to short stay or inconsistent availability, state this explicitly.)

Services & Participation

(Use either the table OR bullets below; omit this entire section if patient was unavailable for the entire period.)

Sessions Offered	Sessions Attended	Notes
[number]	[number]	[Reasons for non-attendance if relevant]

• [Participation quality: initiation level, cueing needs, affect, behavioral regulation, social reciprocity]
• [Engagement patterns: attendance rate, duration tolerated, task persistence]
• [Adaptations provided and patient response]
• [Safety or behavioral incidents relevant to RT] (Only include if applicable.)

Goal Progress

(List each active goal using the format below, ordered by clinical priority. Provide measurable evidence—e.g., attendance rates, duration tolerated, prompts required. If a goal cannot be assessed, include the goal with the note "Unable to assess this interval due to [reason].")

Goal [identifier]: [Goal statement as written in POC]

• Baseline/Prior: [Status at start of interval or last report]
• Current: [Status at end of reporting period with objective data]
• Progress: [Met / Partially Met / Not Met / Regressed / Discontinued]
• Interpretation: [Brief clinical reasoning; barriers and facilitators; if no progress, state why progress is still expected or why goal should be modified]
• Recommendation: [Continue / Modify / Discontinue] [Specify changes if applicable]

(Repeat this Goal block for each active goal.)

Plan

1. [Continue / modify / discharge recommendation with brief rationale]
2. [Updated frequency/duration/intensity for next interval] (Only include if changing.)
3. [Intervention focus: groups, individual sessions, community integration, coping skills, leisure education, adaptive equipment, caregiver training]
4. [New or revised goals] (Only include if applicable.)
5. [Referrals: community resources, adaptive recreation, outpatient services] (Only include if applicable.)
6. [Criteria/timeframe for next reassessment]
7. [Request for updated orders/recertification] (Only include if required by setting.)

Signature: [Signature]

Credentials: [Credentials]

Date/Time: [Date and time]