The purpose of the discharge document is to summarize a patient’s/client’s progress toward goals, status at discharge, and future plans for self-management. Essentially, as the APTA puts it, it is “the last opportunity a therapist has to convey the outcome of physical therapy services. It is also a time to justify the medical necessity for the episode of care.”
To continue to paraphrase the APTA’s description: All discharge summaries should include patient response to treatment at the time of discharge and any follow-up plan, including recommendations and instructions regarding the home program if there is one, equipment provided, and so on. When a patient/client is discharged to another level of service (i.e., from an acute setting to home health or another inpatient setting), evidence of coordination of care should also be included. Issues related to patient/client compliance also may be noted as well as the number of completed visits. A discharge summary should comment if the patient/client stops coming to therapy against recommendation of the physical therapist. If the patient/client is discharged prior to achievement of goals and outcomes, there should be documentation as to the status of the patient/client and the reason for discontinuation. The Board doesn’t dictate how this information is to be included, or in what detail, leaving it up to the PT to determine what is pertinent to the “patient’s/client’s progress toward goals, status at discharge, and future plans.”