Therapeutic Yoga Discharge/Program Completion Summary

Date: [Date of note]

Author: [Name, credentials]

Location/Mode: [Clinic/site]; [in-person / telehealth / hybrid]

Patient: [Name and identifiers per system standard]

Episode Dates: [Start date] – [End date]

Program: [Program name/track] (Include only if applicable.)

Referral Source: [Self-referred / Referring clinician name, credentials]

Disposition: [Completed as planned / Completed early – patient preference / Discontinued – medical change or contraindication / Discontinued – non-attendance / Transitioned to different level of service]

Reason for Completion: [Brief explanation] (Include only if disposition is other than "Completed as planned" or if additional context aids continuity.)

Presenting Indications and Baseline Status

(List indications in decreasing priority. Clearly attribute each to its source: per referral diagnosis, per patient report, or per chart history. Do not infer diagnoses.)

[Indication label] ([per referral diagnosis / per patient report / per chart history]): [Baseline symptom features including onset, duration, frequency, severity, location/quality]; [Baseline functional limitations]; Aggravating factors: [movements/contexts that worsen symptoms]; Easing factors: [movements/contexts that reduce symptoms]

(Repeat for additional indications as applicable.)

Safety considerations influencing yoga plan:

• Precautions/contraindications: [Conditions considered such as glaucoma, pregnancy, fall risk, uncontrolled hypertension, recent surgery, severe osteoporosis]
• Required modifications: [Specific adaptations such as chair-based practice, inversion avoidance, range limitations, breathwork restrictions]

(If safety screening was part of workflow but results are unavailable, state "Safety screening: Not assessed.")

Goals and Baseline Measures

(Include this section only if goals and/or outcome measures were part of care; otherwise omit entirely.)

Patient-stated goals: [List 1–5 concise goals; brief quotes acceptable]

Clinician functional/behavioral goals: [List goals if documented]

Outcome measures: (Include only standardized tools actually collected. Add or remove rows as needed.)

Measure	Baseline (date/value)	Completion (date/value)	Change
[Measure name]	[Date] – [Value]	[Date] – [Value]	[Change with direction]
[Measure name]	[Date] – [Value]	[Date] – [Value]	[Change with direction]

[Brief interpretive sentence noting whether changes meet minimal clinically important difference if known] (If no standardized measures were collected, state: "Standardized outcome measures not collected; outcomes assessed via patient-reported function and clinician observation.")

Course of Care

Utilization summary: [Total sessions] sessions; [Frequency] (e.g., weekly, biweekly); [Duration] minutes per session; Format: [individual / group / mixed]. (For series-based programs: Attendance [attended]/[scheduled]; No-shows/late cancellations: [number]. Note participation limitations only if they affected outcomes.)

Key therapeutic components taught: (Pair yogic terms with plain-language equivalents.)

• Postures/movement: [Focus areas and representative movements with props/modifications used]
• Breath practices: [Techniques with plain-language descriptions and any cautions]
• Relaxation/meditation: [Approaches taught with plain-language names]
• Education: [Topics such as pacing, stress physiology, self-monitoring, pain neuroscience]

Progression and clinical decision-making highlights:

• [Meaningful change in plan and rationale]
• [Meaningful change in plan and rationale]

(Include 2–4 bullets total.)

Adverse events/safety incidents: [Event description, timing, response taken, modifications made, whether referral/escalation occurred] (Include only if events occurred; otherwise omit this line entirely.)

Response and Outcomes

Overall response trajectory: [improved / partially improved / no meaningful change / worsened] (Attribute to patient report and/or measured outcomes. Do not infer improvement without supporting evidence.)

Goal status:

• [Goal] – [Met / Partially Met / Not Met]: [Brief supporting evidence with source attribution]
• [Goal] – [Met / Partially Met / Not Met]: [Brief supporting evidence with source attribution]

(Include all goals documented in Goals section.)

Current limitations and contributing factors: [Residual symptoms; functional limits; barriers to continued progress such as time constraints, fear-avoidance, comorbidities, adherence challenges; risk factors relevant to home practice such as fall risk, orthostatic changes, hypermobility]

Status at Completion

• Symptoms: [Current severity, frequency, typical triggers] (Attribute to patient report or clinician observation.)
• Function: [Activities and roles patient can perform; tasks requiring modification or assistance]
• Self-management capability: [Skills patient demonstrates independently vs. those requiring supervision or cueing]

Escalation guidance: [Patient-specific symptoms that should prompt stopping practice and seeking medical evaluation, tailored to patient's condition] (Include only if clinically indicated based on patient's risk factors.)

Maintenance Home Practice Plan

(Write with patient-facing clarity. Pair yogic terms with plain-language equivalents throughout.)

Plan Overview: Time horizon: [e.g., next 6–8 weeks]; Frequency: [days per week]; Duration: [minutes per session]; Intensity: [gentle / moderate with specific cues]; Rest days: [recommendations]; Format: [written handout / video link / app / recorded audio]. [Patient demonstrated understanding / Performed return demonstration / Additional teaching needed].

Practice Components:

• Warm-up/Preparation (~[X] minutes): [Preparatory movements or breath awareness]
• Main practice (~[X] minutes):
  • [Movement goal]: [Representative poses/movements (plain-language equivalents); hold times or repetitions]
  • [Movement goal]: [Representative poses/movements; hold times or repetitions]
• Breath regulation (~[X] minutes): [Technique name (plain-language description)]; [Cues and pacing]; [Contraindications or modifications if applicable]
• Relaxation/meditation (~[X] minutes): [Approach (plain-language name)]
• Short version for flare days: [Condensed sequence for limited time or symptom flare] (Include only if applicable.)

Progression and Flare Management:

• Progression criteria: [Objective criteria such as increase duration by 2–5 minutes per week if no next-day flare]
• Flare protocol: [What to reduce, what to maintain, when to rest, how to resume baseline]
• Stop rules: [Patient-specific signs/symptoms requiring stopping practice and contacting medical care]

Precautions and Restrictions: [Prohibited or restricted practices with safe alternatives; include posture, movement, breathwork, and environmental cautions as applicable]

Resources: [Recommended class types such as therapeutic, restorative, chair yoga; instructor qualifications to seek; accessibility needs; adherence supports such as habit-stacking, tracking methods]

Recommendations and Follow-Up

(Include only if recommendations, referrals, or follow-up are indicated; otherwise omit this section.)

• Continued practice recommendation: [Independent home program / Continued supervised therapeutic yoga / Transition to community classes]; Rationale: [brief explanation]
• Follow-up plan: [Timing and modality for check-in; trigger-based criteria such as persistent flare beyond X days, new symptoms, adherence barriers]
• Referrals: [Destination; reason; communication sent including date, method, and summary] (Include only if referrals made or recommended.)

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