Massage Therapy Discharge Summary

Patient: [Patient name] — [DOB or approved identifier per clinic policy]

Therapist: [Therapist name], [Credentials] — [License number if applicable], [Clinic/Location]

Episode Dates: Start: [Start date] — Discharge: [Discharge date]

Total Visits: [Number completed] (Include missed/cancelled count only if clinically relevant)

Referring Clinician: [Name, credentials, organization] (Omit this line entirely if self-referred)

Reason for Care & Discharge Disposition

[Primary reason for episode: body region(s), symptom pattern, functional complaint, onset/context] (2–4 sentences; attribute sources, e.g., "per patient report")

Discharge Disposition: [goals met / maximal benefit-plateau reached / patient self-discharged / lost to follow-up / discontinued for safety concern or referral / authorization-coverage limit] — [Brief factual explanation supporting disposition] (If lost to follow-up, state last attended visit date and clarify that status reflects information as of that date)

Initial Status at Start of Care

(Document baseline to enable outcome comparison. Attribute information sources.)

• [Baseline pain severity with scale type, location, typical/worst intensity, aggravating/easing factors] (Patient-reported)
• [Symptom pattern: frequency, triggers, duration, irritability] (Patient-reported)
• [Functional limitations: work tasks, ADLs, sleep, recreation/sport] (Patient-reported)
• [Objective findings within scope: tissue tone, palpable tenderness, movement tolerance, postural observations] (Clinician observation)
• [Precautions/contraindications that influenced treatment approach] (State source)

(If baseline measures were not collected, explicitly state this and reason if known.)

Course of Care Summary

[Episode overview: frequency and duration pattern, primary techniques used (e.g., Swedish, deep tissue, myofascial release, trigger point work), anatomic regions addressed] [Significant clinical decisions: technique modifications, positioning changes, flare management, new precautions] [Adverse events if any and management] (Synthesize at episode level; do not replicate daily notes. For single-visit episodes, state this and summarize that visit only.)

Outcomes Achieved

(Present baseline-to-discharge comparisons. Attribute sources.)

• [Pain severity/frequency/irritability]: Baseline — [Value] → Discharge — [Value] (Patient-reported)
• [Sleep quality or other symptom domains]: Baseline — [Value] → Discharge — [Value] (Patient-reported)
• [Functional capacity (work tolerance, ADLs, activity)]: Baseline — [Activities limited] → Discharge — [Current tolerance/activities resumed] (Patient-reported)
• [Objective findings (tissue tone, tenderness, movement tolerance)]: Baseline — [Finding] → Discharge — [Finding] (Clinician observation)

(If standardized measures not collected, acknowledge this and report based on patient report and clinician observation. If multiple body regions treated, organize by region.)

Goal Attainment:

• [Goal 1] — [Met / Partially Met / Not Met] (Brief explanation if partially met or not met)
• [Goal 2] — [Met / Partially Met / Not Met]
• [Additional goals as applicable]

Clinician Summary: [What improved, what remains, and why discharge is appropriate now]

Current Status & Remaining Limitations

• [Current symptom status: location, severity, frequency, triggers] (Patient-reported)
• [Residual functional limitations and activity tolerance] (Patient-reported)
• [Ongoing precautions/contraindications relevant to self-care or future sessions]
• [Risk factors for recurrence if documented: ergonomics, workload, stress]

Self-Care Plan

(Document specific self-management strategies actually taught during the episode. If none provided or patient declined, state this explicitly rather than inserting generic advice.)

• [Daily/regular activities: stretching, mobility, posture strategies, microbreaks] — [Frequency and duration]
• [Symptom management tools: heat/ice parameters, self-massage technique, pacing strategies] — [Specific instructions]
• [Strengthening or stability exercises if taught within scope] — [Dosage and progression]
• [Education provided and patient understanding if assessed]

Follow-Up & Return Precautions

Follow-Up Recommendations:

• [PRN follow-up / maintenance schedule if discussed]
• [Referrals to other providers if indicated: provider type, reason, urgency level]

Return Precautions:

• Seek care if symptoms worsen despite self-care or significantly limit function
• Seek urgent evaluation for new neurologic symptoms (weakness, numbness, radiating pain) or bowel/bladder changes
• Seek medical evaluation for systemic symptoms (fever, unexplained weight loss) or other red flags
• [Region-specific red flags if discussed]

Signature

Therapist Signature: [Therapist name, credentials, license number]

Date/Time Signed: [Date and time]