Therapy Discharge Summary

The treating therapist or another licensed clinician who is authorized to close the episode should complete it. In many settings, the primary therapist drafts the summary and a supervising clinician reviews it if required by policy. The form is meant to capture the clinical endpoint of care, not a generic administrative note. If multiple disciplines were involved, each discipline can add its own discharge details or contribute to a shared summary.

Use it at the end of a therapy episode when the patient is discharged to home, transferred, referred onward, or stopped because goals were met, progress plateaued, or attendance ended. It is also useful when the patient leaves before all goals are achieved and you need to document residual deficits and next steps. The key is to complete it at the transition point, while the final status, education, and equipment plan are still current. It is not meant for routine visit documentation.

Include the patient identifier, discipline, discharge date, clinician name, and discharge setting, then document the discharge reason and episode outcome. Summarize progress toward goals, current functional status, residual deficits, and any outcome measure used at discharge. If equipment, adaptive devices, or a home program were provided, record what was given and how it should be used. Finish with follow-up recommendations, education provided, and clinician attestation.

It helps create a clear audit trail by tying the discharge reason, outcome, and follow-up plan to a dated clinician attestation. The structure also supports minimum-necessary documentation by focusing on clinically relevant fields rather than free-form narrative. For patient-facing or shared forms, you can add consent language and keep PII limited to what is needed for identification and care coordination. The template also supports consistent documentation across therapists and settings.

Common mistakes include writing a vague discharge reason, leaving goals met as a yes-or-no answer without context, and failing to describe residual deficits clearly. Another frequent issue is listing equipment without specifying fit, use, or who is responsible for obtaining it. Clinicians also sometimes omit the home program summary or follow-up plan, which makes the transition harder for the patient and caregiver. A final pitfall is using the same generic wording for every patient instead of documenting the actual episode outcome.

Yes. The structure works for physical therapy, occupational therapy, speech-language pathology, and other rehab disciplines, but the fields should be tailored to the discipline-specific goals and outcome measures used in that setting. You can rename the functional status section to match your workflow or add conditional logic for discipline-specific equipment and home program fields. Keep the core discharge elements intact so the summary still reads clearly across teams. The goal is consistency without forcing every discipline into the same wording.

Record the name of the outcome measure and the score at discharge, using the exact instrument used in the episode when possible. If the measure was not completed, document why and note any alternative clinical indicators used to assess progress. Keep the field type aligned to the data, such as a numeric input for the score and a short text field for the measure name. This makes the summary easier to review and compare later.

Include whether follow-up is recommended, who should provide it, and the reason for the recommendation. If the patient is being referred to another clinician, specify the target service or discipline and any timing considerations. If no follow-up is needed, state that clearly so the discharge plan is unambiguous. This section should also reflect any patient or caregiver instructions that affect the next step after discharge.