Therapy Discharge Summary

End-of-episode summary form for documenting therapy discharge status, goals met, functional progress, and follow-up recommendations in long-term care or outpatient settings.

Patient and Episode Information

• Patient Identifier
  Use the facility medical record number or internal identifier. Do not enter a full SSN.
• Therapy Discipline
• Episode Start Date
• Discharge Date
• Discharge Setting
• Primary Reason for Discharge

Discharge Status and Goal Attainment

• Overall Discharge Status
• Summary of Goals Met
  Briefly describe the specific goals achieved and the functional outcomes observed.
• Summary of Goals Not Met
  Complete if any goals were not achieved. Include barriers or limiting factors.
• Functional Independence at Discharge
• Overall Progress Toward Goals

Functional Status and Outcome Measures

• Mobility Status at Discharge
• ADL Status at Discharge
• Outcome Measure Name
  Examples: Berg Balance Scale, FIM, TUG, DASH, MoCA.
• Outcome Measure Score at Start
• Outcome Measure Score at Discharge

Recommendations and Follow-Up

• Home Program Provided
• Home Program Details
  List exercises, precautions, frequency, or self-management instructions.
• Equipment or Adaptive Devices Provided
• Follow-Up Recommendations
  Include referrals, reassessment needs, or recommended next level of care.
• Return Precautions or Escalation Instructions
  Document any symptoms or changes that should prompt medical follow-up.

Clinician Attestation

• Clinician Name
• Credentials
• Attestation
  I attest that this discharge summary accurately reflects the therapy episode and discharge status.
• Clinician Signature
• Attestation Date