Aquatic Therapy Discharge Summary (PT/OT)

Patient Name: [Patient full name] DOB: [Date of birth] MRN: [Medical record number]

Discipline: [PT / OT with credentials] Date of Discharge: [Date] Date Authored: [Date]

Referring Provider: [Referring provider name and credentials] Primary Diagnosis: [Primary diagnosis with ICD-10]

Episode Dates: [Start of care date] → [Discharge date] Reporting Period: [Last progress report date] → [Discharge date]

Visit Summary: [Total visits completed] total; [Aquatic visits] aquatic; [Land visits] land (Omit land count if all visits were aquatic.)

Discharge Overview

[Concise discharge narrative] (3–5 sentences. State the specific reason for discharge: goals met / plateau-maximum benefit / transition to land program / patient request / medical status change / attendance-adherence limitation / insurance limitation / other with brief explanation. Provide a headline functional outcome achieved. Summarize current functional status and key residual limitations. Specify transition destination: independent HEP / community aquatics / land-based program / follow-up care. If no final visit occurred, state discharge was completed without final assessment and reference last available data with date.)

Subjective

[Patient-reported functional status compared to baseline] [Relevant symptom status: pain, fatigue, stiffness, water confidence] [Adherence to HEP/program] [Patient priorities for next phase] (Keep concise. Include a brief direct quote only if it meaningfully illustrates function, self-efficacy, or safety concerns.)

Objective — Discharge Status

Standardized Outcome Measures:

• [Measure name] — Baseline: [score] ([date]) → Discharge: [score] ([date]). [One-line interpretation tied to function.]
• (Repeat for each measure used, e.g., TUG, Berg, gait speed, 6MWT, LEFS, ODI, DASH, COPM. If no standardized measure was feasible, document reason and substitute objective functional testing with clear metrics.)

Impairment Measures:

• [Impairment type and location] — Baseline: [value] → Discharge: [value]
• (Include ROM, strength, pain with specific movements, edema, or cardiopulmonary response as relevant to problems/goals. Use baseline → discharge format. Omit measures not tied to functional limitations or goals.)

Functional Performance:

• [Functional task: transfers, gait, stairs, balance, ADLs/IADLs as relevant to goals]
• (Use measurable descriptors: distance, time, assistance level, device used. For OT, include dressing, bathing, meal prep, work tasks as applicable. Avoid vague terms like "improved" without metrics.)

Aquatic Therapy Status: (Required whenever aquatic therapy was delivered during the episode.)

• Pool Parameters: [Typical water depth], [Equipment used: buoyancy devices / aquatic treadmill / rails / resistance equipment]
• Safety and Assistance: [Assistance/supervision level for pool entry/exit]; [Assistance/supervision level for in-water activities] at discharge
• Aquatic Functional Capacity: [Session tolerance/duration], [Water ambulation parameters], [Balance/perturbation tolerance], [Ability to self-progress exercises safely]
• Carryover to Land: [What improved in water] and [whether/how it transferred to land performance with specific metrics]
• (If aquatic discontinued mid-episode, note last aquatic date and reason. If no final aquatic session, document last observed aquatic status and date.)

Goal Attainment

Goal (as written or most recently revised)	Status	Evidence / Barrier
[Goal 1]	[Met / Partially Met / Not Met / Unable to Assess]	[Specific objective measure or functional observation; barrier if not met]
[Goal 2]	[Met / Partially Met / Not Met / Unable to Assess]	[Specific objective measure or functional observation; barrier if not met]
[Additional goals as needed]	[Status]	[Evidence / Barrier]

(Order goals by clinical importance with safety and essential mobility/ADL goals first. If unable to assess at discharge, cite last known data point and date.)

Assessment

[Overall response to skilled therapy with functional relevance] [Remaining impairments and functional limitations] [Clinical reasoning for discharge: why skilled services are no longer required OR why discharge occurred despite remaining limitations] [Safety considerations including falls risk and aquatic safety for independent/community activity] [Prognosis for continued improvement with independent program] (Do not infer goal completion, functional independence, or patient understanding without explicit supporting documentation.)

Plan / Recommendations

Home/Independent Program: [Program type: aquatic HEP / land HEP / combined]; [Frequency and duration guidance]; [Required equipment]; [Progression parameters]; [Red flags/safety parameters for when to stop or seek care]

Transition Plan: [If community aquatics: supervision requirements, safe entry/exit method, device needs] [If land-based care: initial focus areas such as loading tolerance, balance, specific functional tasks]

Follow-up/Referrals: [Follow-up with referring provider: timeframe and reason]; [Recommended referrals if applicable]; [Equipment/orthotic recommendations if applicable]

Education Provided: [Topics covered: HEP instruction, symptom management, pool safety, transition plan]; [Method: demonstration / written handout / teach-back]; [Patient/caregiver understanding and agreement with plan] (If education incomplete due to unanticipated discharge, note what was provided and document attempted contact.)

Signature

Clinician Signature: [Name, credentials, date/time]

[PTA/OTA contributors during reporting period, if applicable] (If assistants contributed, include statement: "Review of treatment notes completed; I agree with the discharge summary and plan.")