Discharge Summaries Study Guide

Who?
● Occupational therapist determines need/ readiness to discontinue services as part of
intervention review.
○ OTA may write discharge note with OT co-signature
● Discharge summaries may be an interdisciplinary note, or each discipline may write its
own summary: MD, case manager, social worker, OT, PT, SLP, any consulting
physicians or department (e.g. endocrinology, wound care)
● The OT should be the one making the decision to d/c services during intervention
review, but it can be in collaboration with OTA and other members of team
● met goals, or insurance said ran out of days, client has failed to progress
● OTA needs to collaborate, can’t do it on their own, can write note but decision to
discontinue comes from both

What?
From Guidelines for Documentation of Occupational Therapy (AOTA, 2013):
● Client information
● Summary of intervention
● Recommendations (skilled nursing therapy, home therapy, outpatient therapy, amount of
assistance needed from caregiver, DME, A/E, grab bars, consultation with another )
● Reason for discontinuation (per clients request, achieved adequate level of functional
independence )
● Progress towards short- or long-term goals depending on length of treatment
● Discharge disposition
● Focus on occupations rather than on changes in client factors or activity demands. (ex.
Don’t focus on ROM increase) ex. Functional tasks such as brush hair
● NOT a session by session recap, but an overview of highlights
● Client info – who, why receiving OT, background and medical history
● Summary of intervention – contain overview of what you did, any specialized modalities
(ex. Splint or home exercise program), ex. Handwriting and fine motor intervention

When to discharge someone

● Client achieves all goals
● Client discharges from facility
● Client refuses to participate in therapy, insurance will stop paying
● Client achieve maximum benefit from therapy and has plateaued
● Client has run out of insurance-approved days
● Other reasons (e.g. client not wishing to continue due to co-pays, etc.)
● Consider duty to treat, ensure no patient abandonment
● Look to Code of Ethics, especially for clients refusing to participate. AOTA has ethics
advisory opinion on patient abandonment
● When notice client running out of days, think about how to maximize time with, be as
functional as possible
● Work with resources that they have -
● Often discharge before met all of goals
● Maintain – keep at that level – for neurodegenerative pt. Only

How?
● SOAP note format (Sames, p. 198-201)
● Narrative format (Sames, p. 202)
● Dates
● Modalities for progress in improvement in client factors – independent with occupations
● Describes follow-up

Example:
● Client is a 55 y.o. woman referred to occupational therapy s/p ORIF of L distal radius fx
resulting from FOOSH. Between 12/1/17 and 2/16/18, client attended 12 weekly 1-hour
OT sessions at outpatient clinic. During this time, client improved wrist extension from
10 degrees to 80 degrees and wrist flexion from 5 degrees to 75 degrees through use of
active and passive ROM, splinting, and electrical stimulation. Client has met all long-
 term and short-term goals and is now independent with ADLs and IADLs, and is able to
type 100 words/minute to allow return to work as an administrative assistant. Client is
independent with night-time splint wearing schedule and home exercise program,
reporting 100% compliance. No further OT needs at this time.

Why write discharge note?

● Continuum of Care
● Provide information about client and their progress to next setting
● Final justification of occupational therapy services and outcomes for insurance
reimbursement
● Reimbursement may be based upon progress (for example, in ARU, change in FIM
scores from evaluation to d/c may influence reimbursement)

Discharge Note – Connie

● Connie is an 80 y.o. woman referred to occupational therapy s/p surgical repair of R
ankle fracture resulting from falling onto bathroom floor. Client is WBAT in walking boot.
Client lives with husband at home who has multiple health problems and ambulates with
walker. For three weeks, client participated in 5x/week 1 hour occupational therapy
sessions in skilled nursing facility focusing on ADLs and IADLs. At time of discharge,
client uses RW for transfers and ADLs. During this time, client improved in several
ADLs including dressing with supervision through use of reacher and sock aid, toileting
with supervision and use of elevated toilet to improve independence, toilet transfers with
supervision at RW, and shower transfer with supervision through use of shower chair
and grab bars. Client can now complete upper body dressing and grooming
independently. Client will be discharged back to her home which is being modified to
meet her needs with a bathroom on the main floor along with a hospital bed in the dining
room. Client should continue to use the Reacher, sock aid, elevated toilet seat, shower
chair, and grab bars when in the home. Further OT in home health may be needed to
address barriers in entering home due to steps. Recommend medical alert system.
Recommend pt have 24-hour supervision, as well as assistance from family caregiver for
ADLs and IADLs. Client discharged from OT services in SNF due to insurance
termination of services. Recommend continued OT in home health setting.
○ 1st sentence describes client and why she’s seeking service
○ 2nd sentence gives the when and where
○ 3rd sentence describes improved client factors (wrist extension/flexion and
modalities)
○ 4th sentence describes improved functioning in occupations
○ 5th sentence describes any follow up client will be doing at home
○ 6th sentence describes what further treatment is needed, recommend adaptive
equipment
● Notes:
○ Review of OT assessment, intervention, and outcome
○ Includes dates of referral, service initiation and discontinuation
○ Summary of client’s progress toward each goal
○ Description of maintenance program and discharge instructions
○ Recommendations for follow-up and referrals to other agencies if needed