Reiki Treatment Plan (Episode of Care)

Patient Name: [Patient full name] (If unavailable, enter "Not provided" and note follow-up to obtain.)

DOB: [MM/DD/YYYY] (If unknown, enter "Unknown" and note source to verify.)

MRN: [Medical record number / Not applicable] (If not applicable, state reason.)

Plan Date: [MM/DD/YYYY]

Author Name and Credentials: [Name, credentials]

Referring Provider: [Referring provider name and credentials / Self-referred] (If unknown, enter "Not provided" and note follow-up.)

Reason for Referral: [Reason for referral in patient-centered terms] (If not provided, state "Not provided" and plan to clarify.)

(Meta: When referencing clinical context or medical history, always attribute the source using phrases such as "per chart," "patient reports," or "per referring provider." Do not state or imply medical diagnoses unless explicitly documented by a licensed clinician and cited as such. When documenting patient experiences during Reiki, attribute them to patient report rather than stating as objective findings. If any section lacks information, include the heading and write "Not assessed" or "To be completed at first session" rather than omitting.)

Clinical Context and Presenting Concerns

[Presenting concern(s) for Reiki in patient-centered language, e.g., stress, pain, sleep disturbance, nausea, feeling overwhelmed] (Include a direct quote of the patient's goals when available. Attribute relevant clinical context to its source, e.g., "per chart," "patient reports," or "per referring provider.")

[Pertinent precautions from history, e.g., post-surgical restrictions, devices/ports, positioning needs, fall risk] (Attribute to source. If no clinical chart exists or this is a wellness-only context, include: "Patient reports no active medical concerns requiring urgent evaluation.")

Informed Consent and Preferences

[Informed consent discussion summary] (Document what was explained: nature and purpose of Reiki as a complementary/supportive modality, that it is not a substitute for medical or mental health care, and realistic expectations given limited evidence base. Include patient questions, how they were addressed, and patient's decision.)

Touch and Proximity Preferences: [hands-on / hands-off / distance]; [areas to avoid]; [positioning needs]; [trauma-informed accommodations, e.g., eyes open, door cracked, support person present, option to stop at any time]

Information Sharing Consent: [Patient consents / does not consent / limited consent] to sharing plan summaries with the referring provider or care team. (Specify any limits.)

Safety Screen

Red Flags Assessed: [Domains screened, e.g., chest pain, severe dyspnea, syncope, stroke-like symptoms, acute psychiatric concerns]

Findings: [None identified / Specific findings] (If concerning findings present, document actions taken.)

Modifications/Avoidance Zones: [e.g., Avoid contact near port; side-lying only; hands-off over specific areas / None]

Emergency Action Plan: [Site-specific protocol, e.g., Stop session, notify RN/provider, follow facility emergency protocol]

Baseline Status and Goals

(Include at least one primary goal with a quantitative baseline measure. If baseline measures are deferred, state "Baseline to be completed at first session" with target date.)

• Goal: [Primary goal, e.g., Relaxation/stress support, Sleep support, Pain self-management support, Coping with treatment-related distress]

  Baseline: [Measure and value with date, e.g., Stress 8/10, validated instrument score]

  Target: [SMART goal with magnitude of change, timeframe, and measurement method]

  Patient Priority: [Patient's own words about why this matters]

• Goal: [Additional goal] (Include additional goals as needed.)

  Baseline: [Measure and value with date / Baseline to be completed at first session]

  Target: [SMART goal]

  Patient Priority: [Patient's words]

Intervention Plan

Modality: Reiki [hands-on / hands-off / distance]; [adjuncts if planned, e.g., guided breathing, body scan, grounding] (If patient prefers spiritual/energy terminology, attribute to patient preference.)

Session Structure: [Check-in with symptom rating and intention-setting] → [Reiki delivery approach] → [Check-out with symptom re-rating, grounding, hydration/rest guidance] (Use neutral clinical language; attribute experiential descriptions to patient.)

Environment and Modifications: [Quiet setting; lighting preference; music; caregiver presence; positioning; avoidance zones]

Episode Parameters

Frequency: [e.g., weekly / twice weekly / PRN with criteria]

Session Duration: [Planned minutes]

Planned Sessions: [Number of sessions / Trial of X sessions then reassess]

Episode Dates: [Start date] to [Anticipated review/end date]

Reassessment Triggers: [Time-based, e.g., after 4 sessions or 4 weeks]; [Outcome-based, e.g., goal met, plateau, symptom escalation]

Outcome Monitoring

• Session-level measures: [Pre/post ratings for primary symptoms using consistent scale]
• Episode-level measures: [Validated instruments if used, administration schedule]
• Action thresholds: Meaningful improvement [define, e.g., ≥2 point change] → continue plan; No meaningful change after [N sessions] → modify approach or frequency; Deterioration or concerning findings → pause and refer/escalate
• Patient Global Impression at Reassessment: [Patient's summary of change and perceived value]

Aftercare and Self-Practice

Aftercare Guidance: [Recommendations tailored to patient, e.g., hydration, rest, gentle movement, grounding/breathing, contact care team for concerning symptoms]

Self-Practice Recommendations: [Specific practices with frequency/duration; barriers discussed; safety instructions for when to stop self-practice and contact a licensed clinician] (Omit if self-practice not discussed.)

Teach-back: [Patient verbalized understanding / Areas needing reinforcement]

Care Coordination

• Care Team Members: [Referring clinician, PCP, specialty providers, RN, others as relevant]
• Patient Consent for Communication: [Consented / Declined / Limited consent]
• Content to Communicate: [Plan summary at initiation; progress at reassessment; urgent concerns]
• Communication Method: [EHR message / phone / secure email per policy]
• Scope Boundary Statement: Reiki practitioner does not diagnose conditions, prescribe treatments, or modify medications; patient directed to appropriate licensed provider for these concerns.

Referral and Escalation Criteria

Emergent (immediate response): New or worsening symptoms suggestive of medical emergency (severe chest pain, severe dyspnea, syncope, stroke-like symptoms); severe mental health safety concerns (active suicidal intent, inability to maintain safety). Action: Stop session, activate emergency protocol, contact [specify].

Urgent (24–72 hours): Rapid symptom worsening despite supportive measures; new neurologic symptoms; concerning screening results. Action: Contact [specify provider/service].

Routine (1–2 weeks): No meaningful improvement after defined trial; patient requests evaluation or treatment beyond Reiki scope. Action: Refer to [specify provider/service].

Plan Continuation and Discharge Criteria

• Continue if: Goals improving; patient desires continuation; no safety concerns.
• Modify if: Partial response; barriers identified; patient prefers different modality or format.
• Discontinue/Discharge if: Goals met and maintenance plan established; plateau after defined trial with no patient-valued benefit; patient preference or inability to participate; safety concerns requiring higher-acuity evaluation.

At discharge, document: Final outcome metrics compared to baseline; self-practice maintenance plan; referrals made; return precautions reviewed.

Scope Statement

Reiki is provided as a complementary, supportive service and is not a substitute for medical or mental health evaluation or treatment. This plan does not constitute diagnosis of any condition or claim that Reiki will cure, treat, or modify any disease process.

Signature

Author Signature: [Electronic signature]

Credentials: [Credentials]

Date/Time: [MM/DD/YYYY HH:MM]

Addendum / Plan Update

(Include only when updating after initial completion; do not overwrite original content.)

Update Date/Time: [MM/DD/YYYY HH:MM]

Reason for Update: [Reason]

[Update content]