Therapy Discharge Summary

This template is used to document the end of a therapy episode in a structured way. It captures the patient’s discharge status, goal attainment, functional progress, outcome measures, and follow-up recommendations. It is designed for outpatient and long-term care settings where a clear discharge record matters for continuity of care and the audit trail.

The treating clinician or supervising therapist should complete it, since the form includes clinical judgment, progress ratings, and attestation. In some workflows, an assistant may draft sections, but the final review and signature should come from the licensed clinician responsible for the episode. That keeps the record aligned with scope of practice and documentation standards.

It is typically used once per therapy episode, at discharge. If your organization uses interim summaries or transfer notes, those are separate documents. This template is not meant for daily treatment notes; it is the final summary that closes the episode and records what happened from start to finish.

List the goals that were met, partially met, or not met, and briefly explain the clinical reason for each outcome. Keep the language specific to function, such as mobility, ADLs, or tolerance for activity, rather than vague statements. If a goal was not met, note whether the patient plateaued, was discharged early, or needs continued care elsewhere.

Yes. It includes fields for the outcome measure name and start/end scores so you can show change over the episode. That makes it easier to compare baseline and discharge status and to support the discharge decision with documented data. Use the same measure at both points whenever possible to keep the record consistent.

Common mistakes include leaving the discharge reason too vague, copying treatment notes without summarizing the episode, and omitting follow-up instructions. Another frequent issue is using free-text where a structured field would be clearer, such as outcome scores or functional independence level. The form works best when it is concise, specific, and complete enough that another clinician can understand the discharge decision.

Yes. The template already includes a therapy discipline field, so you can adapt the wording for physical therapy, occupational therapy, or speech therapy. You can also tailor the functional status fields and outcome measure names to match the discipline and setting. Keep the core structure intact so the discharge record remains easy to review.

It can be used as a standalone discharge form or mapped into an EHR note template. The structured fields make it easier to standardize documentation, support an audit trail, and reduce missing information at discharge. If your system allows attachments, you can also link supporting assessments or home program materials.

After submission, the discharge summary should be reviewed, signed, and stored in the patient record according to your documentation workflow. If follow-up recommendations or return precautions are included, they should be communicated to the patient or caregiver as appropriate. The completed form should also be available for care coordination and future reference.