Recreational Therapy Session Note (SOAP, In-Person/Telehealth)
A concise SOAP-format session note for Recreational Therapy encounters supporting both in-person and telehealth modalities. Captures patient-reported status, RT interventions with skilled components, goal progress, and c…
Document Type
clinical note / Progress Note
Specialties
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Date of Service: [Date of service]
Start Time / End Time: [Start time] / [End time]
Patient: [Name and identifier per facility policy]
Session Type: [Individual / Group / Co-treatment] | [In-Person / Telehealth]
Provider: [Name, credentials]
Attendance: [Present / partial with minutes; others present if relevant]
Telehealth Verification
(Include this section only for telehealth sessions; omit entirely for in-person.)
Modality: [video / audio-only]; Identity verified: [yes / no]; Patient location: [City, State or full address per policy]; Provider location: [City, State]; Consent: [verbal / written]; Privacy: [private / others present]. [Connection issues or observation limitations if applicable] (Include emergency contact and disconnection plan only when clinically indicated or required by policy.)
Subjective
[Patient self-reported status, mood, coping, leisure participation, and symptoms affecting engagement; adherence to carryover activities and barriers; today's priority or goal; direct quote if clinically meaningful] (1–3 sentences. If unable to self-report, note reason and attribute collateral to source.)
Objective
- [Intervention(s) delivered and therapeutic target]
- [Participation, engagement, assistance level, and in-session response]
- [Adaptations used; safety concerns; observation limitations if telehealth]
(For groups: include topic, time in group, and individual participation quality. Include only clinically relevant findings.)
Assessment
[Clinical synthesis integrating subjective and objective findings; goal-based progress status with justification; barriers and facilitators; rationale for continued skilled RT] (2–4 sentences. For telehealth, note modality limitations and need for in-person follow-up if applicable.)
Plan
- [Next session timing and focus tied to treatment goals]
- [Carryover tasks with specific instructions]
- [Education provided; coordination or referrals; safety plan elements as indicated]
Signature: [Provider name, credentials, date/time]
Cosignature: [Supervisor name, credentials, date/time] (Include only if supervision required per policy.)
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