5. Can the last treatment note be the Discharge Summary?

In the case where the PT renders the last treatment, the treatment note and the discharge summary can be in the same document, but the PT should clearly identify treatment given that day and any other information pertinent to that treatment session as well as the information expected in the Discharge Summary.  If the PTA […]

4. What’s the difference between discharge and discontinuation?

As far as the Board’s rules are concerned, there is no difference.  The purpose of the summary is to record all of the pertinent information at the time treatment ends – regardless of whether the patient met goals, quit coming to therapy, or transitioned to another setting.  In some settings, such as the ECI or […]

3. What must be in the Discharge Summary?

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 […]

2. Who can complete the Discharge Summary?

Only the PT can complete the discharge summary, because it is based on the PT’s analysis of the patient’s/client’s achievement of the predicted goals and expected outcomes. The PTA may provide subjective and objective information for the discharge summary, but may not complete the evaluative portion of the discharge summary or develop the follow-up plan. […]