PT Discharge Summary and Functional Status

Physical therapy discharge summary form to document goals met, final outcome measure scores, functional status change across the episode of care, and the home exercise program at discharge.

Patient and Episode Information

• Patient Identifier
  Use the internal medical record number or other approved identifier. Do not enter SSN or other unnecessary PII.
• Episode Start Date
• Discharge Date
• Discharge Setting
• Discipline

Discharge Reason and Status

• Reason for Discharge
• Completed Plan of Care?
• Discharge Summary
  Brief narrative of the episode outcome, including response to treatment and functional change.
• Current Functional Limitations at Discharge

Goal Attainment

• Overall Goal Status
• Goals Met Summary
  Summarize the measurable goals achieved during the episode.
• Goals Not Met or Partially Met
  Explain barriers, remaining deficits, or why goals were not fully achieved.
• Goal-by-Goal Status
  Add each discharge goal and its final status.

Outcome Measures and Functional Status

• Outcome Measure Name
• Baseline Score
  Enter the initial score from the start of care if available.
• Final Score
• Higher Score Indicates
• Functional Status Change Summary
  Describe the change in mobility, pain, strength, endurance, balance, or activities of daily living from baseline to discharge.
• Assistive Device Status at Discharge

Home Program and Follow-Up

• Home Program Provided?
• Home Exercise Program Details
  Include exercises, dosage, precautions, and patient education provided at discharge.
• Follow-Up Recommendations
  Include referral recommendations, return precautions, or instructions for re-evaluation if symptoms worsen.
• Patient Understanding of Discharge Instructions

Clinician Attestation

• Clinician Name
• Credentials
• Signature
• Attestation