Occupational Therapy Discharge Summary (Episode of Care)

Note Type: Occupational Therapy Discharge Summary

Patient: [Full name and one additional identifier (MRN or DOB)]

Service Setting: [Clinical setting and location]

Episode Dates: [Start of care date] through [Discharge date]

Total Visits: [Number of OT visits completed] (Note missed/canceled visits if relevant to discharge rationale)

Therapist: [Treating OT or OTA with credentials] (If services delivered by OTA, include supervising OT name and credentials)

Referring Provider: [Name and role, if applicable]

Primary Diagnosis: [Reason for OT referral stated as a functional problem]

Relevant Medical History: [Pertinent diagnoses affecting OT treatment, or "None"]

Precautions: [Weight-bearing restrictions, spinal precautions, cognitive/behavioral safety concerns, or "None"]

Discharge Summary

[1–4 sentence synopsis covering: why OT was initiated, key functional outcomes achieved, why OT is ending, and next care setting/plan] (Use plain language. If discharge was unplanned, state explicitly with date of last observed status.)

Reason for Discharge

Disposition: [home / home with assistance / SNF / IRF / LTACH / acute care / hospice / lost to follow-up / other]

Primary Reason: [goals met / maximum benefit reached / no longer requires skilled OT / transition to different care level / patient preference or refusal / medical change / non-adherence]

Secondary Factors: [Transportation, coverage limits, caregiver availability, or "None"]

Skilled Need Closure: [Statement indicating whether patient can safely carry out plan independently or with caregiver support, specifying what has stabilized]

Functional Status: Start of Care vs Discharge

(Include only domains addressed during this episode. Use consistent assistance levels: Independent / SBA / CGA / Min A / Mod A / Max A / Dependent.)

Domain/Task	Start of Care Status	Discharge Status	Notes
[Domain: ADLs, IADLs, transfers, UE function, cognition/perception, activity tolerance, home/environmental factors]	[Baseline performance and assistance level]	[Discharge performance and assistance level]	[Residual deficits, safety considerations, equipment needs]
[Additional domain]	[Baseline status]	[Discharge status]	[Notes]

(Add rows for each domain addressed. Note "Not assessed at discharge" with rationale if applicable.)

Outcome Measures

• [Measure name]: [Dates administered] | Baseline: [Score] | Discharge: [Score] | Interpretation: [One-line functional meaning]

(Include standardized measures and patient-reported outcomes. If none used, document rationale and substitute objective indicators such as task completion time, cue levels, or error rates.)

Goal Attainment

(List safety-critical goals first, then patient priorities.)

Goal	Baseline	Discharge	Status	Barriers/Facilitators
[Goal as written in plan of care]	[Baseline for this goal]	[Discharge status for this goal]	[Met / Partially Met / Not Met]	[Key barriers or facilitators; plan if not met]
[Additional goal]	[Baseline]	[Discharge]	[Status]	[Barriers/Facilitators]

Interventions Provided

(Include only categories actually delivered. Briefly note skilled judgment applied.)

• [ADL/IADL training and compensatory strategies]
• [Therapeutic exercise and neuromuscular re-education]
• [Fine motor/coordination training]
• [Cognitive/perceptual training and/or vision strategies]
• [Splinting/orthoses fabrication and management]
• [Assistive technology and adaptive equipment training]
• [Environmental modification and home safety training]
• [Caregiver training]

Equipment and Modifications

Issued/Provided:

• [Device name and type] — [Wear schedule/skin check requirements/care instructions] — Patient/caregiver competency: [Demonstrated / Requires additional training]

Recommended but Not Obtained:

• [Device] — Barrier: [cost / payer denial / patient preference] — Alternative: [Interim solution provided]

Environmental Modifications:

• [Modification] — [Location] — Status: [Completed / Pending installation]

Education and Training

• Learner: [patient / caregiver / family member] Topic: [Condition management, ADL strategies, transfer techniques, fall prevention, energy conservation, joint protection, orthosis care, safety awareness] Method: [Demonstration, teach-back, written materials] Competency: [Observable statement of learner response]
• Safety warning signs reviewed: [Symptoms that should prompt medical follow-up]

(If caregiver support is needed but unavailable, document as discharge risk with mitigation plan.)

Home Program

Program Components: [Exercise categories, functional practice activities, cognitive strategies, orthosis wear schedule]

Dosage: [Frequency, intensity, duration, progression criteria]

Precautions: [Pain thresholds, restrictions, stop rules]

Adherence Support: [Reminders, caregiver role, tracking method]

Materials Provided: [Handouts, printed instructions, digital resources]

(Identify 3–5 core priorities if program is extensive. If patient declined HEP, document refusal and risks discussed.)

Follow-Up Recommendations

• Therapy Services: [OT in different setting / PT / SLP / other rehabilitation]
• Medical Follow-Up: [Relevant specialty appointments and timing]
• Community Resources: [Adaptive programs, driver rehab, vocational rehab, support groups]
• Pending Needs: [Equipment acquisition, additional training, home assessment]
• Return Precautions: [Falls, worsening pain, new neurologic symptoms, skin breakdown, inability to complete essential ADLs safely]

Signature

Therapist Signature: [Name, credentials, date]

Supervising OT Signature: [Name, credentials, date] (Include if services delivered by OTA)

(If information is unavailable, document "Not assessed" or "Unable to determine from available record." For unplanned discharges, base status on last treatment session and note date of last observation.)