IRF Discharge Summary (Rehab)

Patient: [Full name] | MRN: [MRN] | DOB: [DOB] | Age: [Age] | Sex: [Sex]

IRF Admission Date: [Date] | Discharge Date: [Date]

Attending Physician: [Name, credentials]

Discharge Destination: [Home with family / Home alone / Assisted living / SNF / LTACH / Acute care / Other]

Primary Contact/Caregiver: [Name] ([Relationship]) | Phone: [Number] | Interpreter needs: [None / Language and modality]

Discharge Snapshot

• [Rehabilitation diagnosis with impairment and etiologic condition]
• [Most important active problems at discharge, 3–6 items]
• [Functional status headline: mobility level, ADL assist level, cognition/communication, diet/swallowing, bladder/bowel]
• [Restrictions and precautions: weight-bearing, spine/hip precautions, aspiration, fall risk]
• [Discharge services arranged: therapy setting, home health, nursing needs, DME]
• [Critical follow-ups within 7–14 days]
• [Red-flag return precautions: when to call vs go to ED]

(Provide 4–8 bullets total using concise, high-yield phrasing readable in under 30 seconds.)

Discharge Diagnoses

1. Primary rehabilitation diagnosis: [Impairment] due to [Etiologic diagnosis] [ICD-10 code]
2. Active medical problems requiring ongoing management: [Problem 1] [ICD-10]; [Problem 2] [ICD-10]; [Problem 3] [ICD-10] (Label uncertain items as "suspected" or "concern for.")
3. Complications during IRF stay: [Complication and status] [ICD-10] (Omit if none.)

Allergies

• [Drug name] — [Reaction type/severity]
• [Non-drug allergy relevant to care/DME] — [Reaction/context]

(If allergies cannot be verified, state "Allergy history unverified" and describe mitigation plan.)

Disposition and Condition

• Discharge destination and receiving provider/agency: [Setting and address/agency] | [Receiving clinician/contact]
• Condition at discharge: [Stable / Guarded] (Include brief justification if guarded.)
• Code status: [Full code / DNR / DNI / POLST details] | Surrogate decision-maker: [Name, relationship, contact] (Include only if applicable.)

Procedures, Devices, Wounds, and Lines

(Include this section only if applicable; omit entirely if none.)

• Procedures during IRF stay: [Procedure; Date; Key outcome]
• Active devices/implants at discharge: [Device type and side/spec; purpose; care instructions]
• Wounds and skin issues: [Location; stage/type; dressing regimen; change frequency; offloading instructions]
• Lines/tubes/catheters: [Type; insertion date; indication; care/flush protocol; removal plan]

Rehabilitation Course

Therapy overview: [Disciplines involved] | [Average minutes/day and tolerance] | [Barriers to participation: pain, orthostasis, fatigue, cognition, mood, medical instability]

Domain	Admission Status	Discharge Status	Notes
Bed mobility	[Level of assist/device]	[Level of assist/device]	[Key safety issues/variability]
Transfers	[Level of assist; method/device]	[Level of assist; method/device]	[Technique; cues required]
Ambulation	[Distance; device; surface]	[Distance; device; surface]	[Gait quality; endurance; safety]
Wheelchair mobility	[Type; distance; assist]	[Type; distance; assist]	[Set-up needs; pressure relief]
Stairs/steps	[Number; rail; assist]	[Number; rail; assist]	[Technique; home environment fit]
Toileting	[Assist level; equipment]	[Assist level; equipment]	[Continence; timing; safety]
Bathing	[Assist level; equipment]	[Assist level; equipment]	[Shower vs sponge; safety]
Dressing	[UE/LE assist; equipment]	[UE/LE assist; equipment]	[Technique; brace management]
Feeding	[Assist; set-up; devices]	[Assist; set-up; devices]	[Endurance; aspiration risk]
Communication	[Speech/voice; aphasia/dysarthria]	[Speech/voice; aphasia/dysarthria]	[AAC used; strategies]
Cognition	[Attention; memory; executive function; safety awareness]	[Attention; memory; executive function; safety awareness]	[Cueing; supervision needs]
Swallowing/Nutrition	[Diet texture; liquid consistency; supervision]	[Diet texture; liquid consistency; supervision]	[Strategies; precautions]
Bladder/Bowel	[Continence; program/devices; assist]	[Continence; program/devices; assist]	[Schedule; medications; supplies]

(Include only domains relevant to patient's rehabilitation stay.)

Section GG summary: [Selected high-yield items or brief interpretation of functional gains and remaining limitations] (Include if available.)

Therapy Discipline Summaries

Physical Therapy

• Primary impairments addressed: [Impairments]
• Key interventions: [Interventions]
• Goals: [Met / Partially met / Not met] (Brief rationale.)
• Assist required at discharge: [Level and tasks]
• Home exercise program: [Provided / Not provided] | Caregiver trained: [Yes / No]

Occupational Therapy

• Primary impairments addressed: [Impairments]
• Key interventions: [Interventions]
• Goals: [Met / Partially met / Not met] (Brief rationale.)
• Assist required at discharge: [Level and tasks]
• Home program/adaptive strategies: [Provided / Not provided] | Caregiver trained: [Yes / No]

Speech-Language Pathology

• Primary impairments addressed: [Communication / Cognition / Swallowing]
• Key interventions/strategies: [Interventions]
• Goals: [Met / Partially met / Not met] (Brief rationale.)
• Assist/supervision at discharge: [Level and contexts]
• Home program/compensatory strategies: [Provided / Not provided] | Caregiver trained: [Yes / No]

(Include only disciplines involved in patient's care.)

Caregiver Training

(Include if discharge requires caregiver assistance.)

• Who trained: [Names/relationships]
• Skills trained: [Transfers; mobility; brace management; tube feeding; wound care; equipment use; precautions]
• Teach-back demonstrated: [Yes / Partially / No] (If incomplete, document mitigation plan and additional supports arranged.)

Medical Course

(Problem-oriented summary in descending clinical priority. Align problems with discharge diagnoses, medication changes, and follow-up plans.)

[Problem 1: Diagnosis/condition]

• Course and current status: [Brief status/trajectory]
• Key diagnostics: [Studies/results and dates]
• Treatments and adjustments: [Medications/procedures and response]
• Monitoring needs and contingency plan: [What to monitor; thresholds for action]
• Follow-up responsibility: [PCP / Specialist] ([Timeframe])

[Problem 2: Diagnosis/condition]

• Course and current status: [Brief status/trajectory]
• Key diagnostics: [Studies/results and dates]
• Treatments and adjustments: [Medications/procedures and response]
• Monitoring needs and contingency plan: [What to monitor; thresholds for action]
• Follow-up responsibility: [PCP / Specialist] ([Timeframe])

(Add additional problems as clinically indicated.)

Medications at Discharge

(If reconciliation is incomplete, explicitly describe limitations and mitigation plan.)

Continue from Home

Medication (generic)	Dose	Route	Frequency	Indication	Special instructions
[Name]	[Dose]	[Route]	[Frequency]	[Indication]	[Instructions]

New at Discharge

Medication (generic)	Dose	Route	Frequency	Indication	Special instructions
[Name]	[Dose]	[Route]	[Frequency]	[Indication]	[Instructions]

Dose Changed

Medication (generic)	New dose	Route	Frequency	Indication	Change rationale
[Name]	[Dose]	[Route]	[Frequency]	[Indication]	[Rationale]

Stopped

• [Medication] — [Reason for discontinuation]

PRN Medications

Medication (generic)	Dose	Route	Indication	Max frequency	Special instructions
[Name]	[Dose]	[Route]	[Indication]	[Max frequency]	[Instructions]

High-risk medication safety notes: [Anticoagulants / Insulin / Opioids / Sedatives / Antipsychotics / Antiepileptics: monitoring plan, hold parameters, reversal/precautions] (Include only for applicable medications.)

Antimicrobials: [Agent; indication; start date; planned stop date; pending cultures and who will follow] (Include only if applicable.)

DME, Orthotics, and Supplies

(Include only if equipment or supplies were provided/prescribed; omit section if none.)

• Device/supply: [Item and size/spec] | Fit/training: [Completed / Pending] | Vendor: [Name/contact] | Safety notes: [Key precautions]
• Home modifications recommended: [Grab bars; ramps; hospital bed; bedside commode; other]
• Supplies ordered: [Wound dressings; catheter supplies; tube feeding supplies with quantities]

Discharge Services and Follow-Up

• Therapy plan: [Setting: Home health / Outpatient / Day rehab / SNF] | [Disciplines: PT/OT/SLP] | [Frequency if known]
• Skilled nursing needs: [Wound care; medication management; tube feeds; injections; labs with timing]
• Social work/case management: [Benefits; transportation; caregiver resources; community services]

Scheduled Follow-Up Appointments

Date	Time	Provider/Service	Location	Contact
[Date]	[Time]	[Provider]	[Address/Clinic]	[Phone]

Recommended Follow-Up (Not Yet Scheduled)

• [Provider/Service] — [Timeframe] — [Reason]

Monitoring Plan

• [INR / CBC / BMP / HbA1c / Glucose logs / Blood pressure / Weight / Wound assessment] — [Frequency] — [Responsible clinician/service]

Pending Studies/Results

• [Test] — [Expected date] — Accountable for review: [Clinician/service]

Return Precautions and Instructions Provided

• Instructions reviewed with: [Patient / Caregiver / Both] covering: [Activity/mobility restrictions; medication changes; diet/swallowing precautions; wound/skin care; equipment use/safety]
• When to call vs go to ED: [Red-flag symptoms and thresholds]
• Teach-back performed: [Yes / Partially / No] (If gaps identified, document reinforcement plan.)
• Written instructions: [Discharge packet / Patient portal / Provided with DME]

Communication and Authentication

• Discharge summary sent to: [PCP and relevant specialists / Available in shared EHR] ([Date/time])
• Medication list provided to: [Patient/caregiver] and [Next care setting/provider]
• Referrals placed and accepted: [Home health / Outpatient therapy / Specialty clinics with authorization status]

Electronic Signature: [Clinician name, credentials] | Date/Time: [Date and time signed]

(For core elements—diagnoses, disposition, medications, follow-up—include the section and explicitly note what is unavailable with mitigation plan. For conditional sections—procedures, wounds, DME—omit entirely if not applicable. Do not infer functional independence or caregiver support; document based on therapy and nursing observations.)