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Run: Therapy Discharge Summary

Therapy Discharge Summary template for documenting episode status, goal attainment, functional progress, and follow-up recommendations at discharge. Use it t...

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Patient and Episode Information

Patient Identifier (required)

Use the facility medical record number or internal identifier. Do not enter a full SSN.

Therapy Discipline (required)

Episode Start Date (required)

Discharge Date (required)

Discharge Setting (required)

Primary Reason for Discharge (required)

Discharge Status and Goal Attainment

Overall Discharge Status (required)

Summary of Goals Met (required)

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 (required)

Overall Progress Toward Goals (required)

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

Yes No N/A

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 (required)

Credentials

Attestation (required)

I attest that this discharge summary accurately reflects the therapy episode and discharge status.

Yes No N/A

Clinician Signature (required)

Attestation Date (required)

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Email (required)

Your name (optional)

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