Complementary/Integrative Therapy Discharge Summary (Completion of Care)

Patient Name: [Patient full name]

DOB/MRN: [DOB; MRN]

Episode Start Date: [Start date]

Discharge Date: [Discharge date / Unable to assess—patient missed final visit]

Total Visits: [Total number of visits and cadence, e.g., "6 visits, weekly"]

Clinician Name and Credentials: [Clinician name, degrees, licenses]

Referring Clinician: [Referring clinician name and credentials / Self-referred]

Reason for Discharge: [planned completion / patient elected to stop / referred out / lost to follow-up / safety concern / other: specify]

Executive Summary

[Concise overview of presenting concerns addressed, modalities used and progression, key outcomes (objective or patient-reported), remaining limitations, and headline of home program and follow-up plan]

(Write 4–6 sentences so a clinician can quickly understand what was treated, what was done, what changed, what remains, and what to do next. Use direct patient quotes only when they materially clarify outcome or discharge decision. If information is missing, state explicitly, e.g., "Unable to assess—patient missed final visit.")

Problems Addressed

(List problems in order of clinical impact. Add or remove items as needed. If goals were not formally established, state: "Not formally established—episode focused on symptom management and education.")

1. [Problem name—clinical or functional description]

   • Baseline: [Functional impact/limitations at episode start]
   • Episode Goal: [Measurable goal when possible]

2. [Problem name]

   • Baseline: [Functional impact/limitations]
   • Episode Goal: [Measurable goal when possible]

Pertinent Background and Safety Considerations

(Include only if directly relevant to modality selection, precautions, or outcome interpretation. Omit this section entirely if no safety factors were relevant.)

• [Comorbidities affecting care, e.g., anticoagulation, neuropathy, pregnancy, immunosuppression]
• [Contraindications identified and how addressed]
• [Device/implant considerations]
• [Relevant allergies or sensitivities to products used]
• [Concurrent treatments affecting interpretation of outcomes]
• [Screened—no contraindications identified] (Include only if screening was actually performed)

Interventions and Course of Care

(For each modality used, document parameters and tolerance. For brief episodes of 1–2 visits, a single paragraph combining modality details and course is sufficient.)

• [Modality name] — [Frequency and duration, e.g., "weekly x 8"]; [Key parameters: technique approach, regions addressed, session duration, adjuncts]; [Tolerance summary: "well tolerated, no adverse events" or specify]
• [Modality name] — [Frequency and duration]; [Key parameters]; [Tolerance summary]

Course of Care: [Narrative describing initial rationale, major modifications and why, notable milestones or setbacks, and coordination with other providers]

(1–2 paragraphs. If episode was truncated or patient missed final visit, state explicitly.)

Outcomes at Discharge

(Organize by problem number from Problems Addressed. If discontinuation was unplanned, document last known status and reason.)

1. [Problem 1]

   • Goal Status: [Achieved / Partially Achieved / Not Achieved / Unable to Assess]
   • Supporting Evidence: [Objective measure change, functional change, or patient-reported outcome]
   • Contributors/Barriers: [Adherence, comorbidities, access, flare, etc.] (Include if relevant)

2. [Problem 2]

   • Goal Status: [Achieved / Partially Achieved / Not Achieved / Unable to Assess]
   • Supporting Evidence: [Objective measure change, functional change, or patient-reported outcome]
   • Contributors/Barriers: [If relevant]

Objective Measures and Patient-Reported Outcomes

(List standardized measures with baseline and discharge values. If none used, document what was used instead.)

• [Measure name]: Baseline [value] ([date]) → Discharge [value] ([date])
• [Alternate tracking method and summary, if no standardized measures]

Current Functional Status: [Brief summary of function and symptom control at discharge]

Discharge Disposition: [completed plan / transitioned to self-management / referred out / lost to follow-up / other: specify]

Remaining Limitations and Red Flags

(Include if applicable; omit this section if no significant limitations remain and no red flags were reviewed.)

• Persistent Limitations: [Functional or symptom-related limitations]
• Known Triggers and Mitigation: [Triggers identified and strategies to manage]
• Escalation Triggers Reviewed: [Specific symptoms or functional changes warranting urgent evaluation]

Self-Management and Home Plan

(Provide patient-friendly, forward-looking guidance. If no home program was provided, explicitly document why, e.g., "No home program provided—consult-only episode for second opinion.")

• Components: [Exercises / stretches / breathwork / meditation / self-care techniques / sleep hygiene / pacing strategies]
• Frequency and Duration: [e.g., daily, 10 minutes, 2–3 sets]
• Progression and Stop Rules: [How and when to progress; when to stop or modify]
• Safety Precautions: [Contraindications, modifications, warning signs]
• Materials Provided: [Handouts, links, apps, logs]
• Adherence Supports: [Reminders, habit strategies, accountability plan]

Follow-Up Plan

• Return PRN Criteria: [Specific symptom severity/duration thresholds, functional regression indicators, new/worsening symptoms warranting evaluation]
• Maintenance Visits: [Suggested interval and rationale; patient preference; criteria to taper or discontinue] (If recommended)
• Referrals: [Referrals made or recommended; responsible party for placing]

(If no follow-up needed, document: "No scheduled follow-up; self-management plan in place; return criteria reviewed.")

Supplements and Products Discussed

(Include only if supplements, herbals, topicals, or related products were addressed during the episode. Omit this section entirely if none discussed. Do not infer counseling occurred unless explicitly documented.)

• [Product name, dose form]: [Dose/usage instructions]; [Key counseling points]; [Interaction cautions]; [Coordination advice given re: prescribing clinicians]

Adverse Events

(Include only if adverse events or complications occurred during the episode. Omit this section entirely if none. Use factual language; avoid speculative causality.)

• Event: [Description of what happened]
• Timing/Severity: [Onset relative to session; severity grade]
• Management: [Actions taken]
• Outcome: [Resolved / ongoing; follow-up required]
• Reporting: [Reports filed, clinicians notified, if applicable]

Clinician Signature: ________________________________

Credentials: [Credentials]

Date: [Date signed]