Therapy Animal Suitability & Contraindication Screening (Patient)

Date/Time of screening: [Date and time]

Author role/credentials: [Name, role, credentials]

Department/Service: [Department or service name]

Encounter context: [inpatient / outpatient] — [Unit/Ward] — [Room/Bed]

Primary team: [Primary team or service responsible]

AAT program identifier: [Program name or identifier / Unknown]

Therapy animal team: [Team identifier / Not yet assigned]

Screening Summary

Eligibility Decision: [Cleared for AAT without restrictions / Cleared for AAT with restrictions / Not cleared for AAT at this time / Deferred—additional information required]

Primary Drivers: [1–3 key factors supporting decision] (e.g., isolation precautions, severe allergy, open wound, agitation risk)

Effective Date/Time: [Date and time decision takes effect]

Reassessment Trigger: [Clinical change prompting re-evaluation] (e.g., "Reassess when isolation precautions discontinued")

Notifications: [Parties informed: AAT coordinator, bedside nursing, infection prevention, primary team as applicable]

Reason for Screening

[Screening trigger] (e.g., new AAT referral, repeat visit, change in clinical status, unit transfer, post-operative status)

• Planned interaction type: [facility therapy animal visit / patient-owned pet visitation / group activity / other]
• Planned contact level: [visual only / touch allowed / animal on bed or lap / group activity]
• Intended visit location: [bedside / dayroom / group room / outdoor courtyard / other]

Consent and Patient Preference

Decision-maker: [Patient with capacity consents / Patient declines / Surrogate consents / Surrogate declines / Unable to obtain—specify reason]

Surrogate information (if applicable): [Name, relationship, authority]

Assent/Dissent (if limited capacity): [Observable assent or dissent] (Use brief behavioral description; quote key phrases if refusal or strong preference is a primary driver.)

Preferences/Restrictions: [Species preference, contact limits, distance preference, cultural/religious/trauma-related considerations] (Include only if volunteered by patient.)

Contraindication Screening

(For each domain, document status, details when positive, and resulting action. Do not infer immunocompromised status, isolation status, or allergies—verify explicitly.)

• Allergies and Respiratory Sensitivity:
  • Status: [Present / Absent / Unknown / Not assessed]
  • Details: [Animal allergy with species if known, dander/saliva sensitivity, prior reaction history, asthma/reactive airway triggers, severity; include roommate allergy if shared room]
  • Action: [None required / Restriction / Visual-only visit / Contraindication / Consult allergy/pulmonary / Verify before proceeding]
• Fear, Phobia, or Aversion:
  • Status: [Present / Absent / Unknown / Not assessed]
  • Details: [Patient-reported fear/phobia/aversion; roommate concerns if shared room] (Patient preference alone is sufficient basis to decline.)
  • Action: [None required / Decline visit / Visual-only at distance / Supervised desensitization if protocol exists / Contraindication]
• Immunocompromised Status:
  • Status: [Present / Absent / Unknown—requires primary team confirmation / Not assessed]
  • Details: [Clinical basis if present; protective environment status] (Do not infer; confirm with primary team or chart review.)
  • Action: [None required / Individualized risk-benefit review required / Visual-only / Contraindication / Defer pending team confirmation]
• Isolation and Transmission-Based Precautions:
  • Patient-level precautions: [None / Contact / Droplet / Airborne / Enhanced / Other—specify]
  • Unit-level outbreak restrictions: [Present / Absent / Unknown]
  • Implication: [Proceed per policy / Not cleared for in-room visit / Visual-only at doorway / Defer until precautions discontinued]
• Skin Integrity, Wounds, and Devices:
  • Status: [Present / Absent / Unknown / Not assessed]
  • Details: [Open wounds, incisions, ulcers, burns, ostomies, bandaged areas; invasive devices such as IV, central line, drain, feeding tube; ability to reliably avoid contact]
  • Action: [None required / Keep animal off bed / No contact with dressings or device sites / Use barrier / Visual-only / Contraindication]
• Behavioral Safety:
  • Status: [Present / Absent / Unknown / Not assessed]
  • Details: [Agitation, delirium, confusion, severe impulsivity, intoxication/withdrawal; risk of bite/scratch, device dislodgement, or handler safety concerns] (Use behaviorally anchored descriptions.)
  • Action: [None required / Temporary deferral pending stabilization / Require staff supervision / Contraindication this admission]
• Setting Appropriateness:
  • Intended location status: [Permitted / Restricted / Requires exception approval]
  • Details: [Location and any restrictions; if exception required, document approval source and date]
  • Action: [Proceed as planned / Modify to permitted location / Defer pending approval / Not cleared]

Mitigations and Conditions for Visit

(Include only when disposition is Cleared with or without restrictions. If Not cleared or Deferred, state "N/A—not cleared for visit" and omit bullets.)

• Hand hygiene for patient and contacts before and after interaction
• No contact with saliva / no licking [if applicable]
• Avoid contact with wounds, dressings, and device insertion sites [if applicable]
• Animal placement: [off bed / on bed with clean barrier and patient consent]
• Feeding/treat restrictions: [none allowed / permitted per handler only]
• Environmental cleaning per policy
• Supervision: [handler discretion to terminate / bedside staff present]
• [Additional patient-specific restrictions]

Coordination and Documentation

Notifications completed: [AAT program coordinator / Bedside nursing / Primary team / Infection prevention] — [Date/time]

Consults placed: [Service and reason / None]

Visit logging for contact tracing: [Planned date/time window], [Unit/Room], [Therapy animal team identifier] (Note if identifiers will be captured at time of visit.)

Follow-up actions: [Items to verify or reassess and timeframe]

Signature

[Electronic signature: Name, credentials, role] — [Date/Time]