Physical Therapy Discharge Summary (Episode of Care)

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

Date of Discharge Summary: [Date] Author: [Clinician name, credentials]

Episode Start Date: [Date] Discharge Date: [Date] Total Visits Attended: [Number]

Primary Diagnosis: [Primary diagnosis for therapy] Referring Provider: [Referring provider name and credentials] (Include if applicable)

Discharge Information

• Discharge Disposition: [Self-management/home program / Transition to another provider / Physician follow-up / Other]
• Discharge Reason: [Goals met / Functional plateau / Patient request / Non-attendance / Medical status change / Insurance limitation / Other]
• Planned vs Unplanned: [Planned / Unplanned]
• Last Contact and Outreach Attempts: [Last contact date; summary of outreach attempts] (Include only if unplanned discharge without final assessment)

Episode Synopsis

• [Presenting problem and baseline functional limitations]
• [Key intervention categories and notable progressions]
• [Significant barriers or contextual factors] (Include only if applicable)
• [Overall trajectory: improved / plateaued / regressed with brief explanation]

Status at Discharge

(Document status as of discharge date; if measures were obtained on a different date, note that date explicitly.)

Subjective

• [Current symptom report including location, intensity, and stability] (Use attributed statements, e.g., "Patient reports...")
• [Perceived functional change since start of care]
• [Current activity tolerance and participation level]
• [Home program adherence] (Include if relevant to discharge)

(If patient was not seen at discharge, state: "Subjective status unavailable; last documented on [date].")

Objective

(Include only clinically decision-driving measures tied to goals. Limit to 5–8 key measures. Reference flowsheets for complete data.)

• [Measure name]: Baseline [value]; Discharge [value] (If not assessed, state reason)
• [Measure name]: Baseline [value]; Discharge [value]
• [Measure name]: Baseline [value]; Discharge [value]
• [Measure name]: Baseline [value]; Discharge [value]

Standardized Outcome Measures

(Omit this subsection entirely if no standardized measures were administered.)

• [Outcome measure name]: Baseline [score]; Discharge [score] (Note if change exceeded clinically meaningful threshold, when established)
• [Outcome measure name]: Baseline [score]; Discharge [score]

Goal Attainment

(For unplanned discharge where reassessment was not possible, mark goals "Unable to assess—status based on last visit [date].")

Goal	Baseline	Discharge Status	Outcome
[Long-term goal statement]	[Baseline performance]	[Discharge performance]	[Met / Partially Met / Not Met / Unable to Assess] (If not met, note barrier)
[Long-term goal statement]	[Baseline performance]	[Discharge performance]	[Met / Partially Met / Not Met / Unable to Assess]
[Additional goal] (Add or remove rows as needed)	[Baseline performance]	[Discharge performance]	[Met / Partially Met / Not Met / Unable to Assess]

Remaining Deficits

(Include this section only when deficits remain at discharge; omit entirely if patient achieved full resolution.)

• Impairments: [e.g., limited ROM, weakness, pain, balance deficits]
• Activity Limitations: [e.g., difficulty with stairs, prolonged standing, lifting]
• Participation Restrictions: [e.g., not yet returned to work/sport/recreation]
• Safety Concerns: [e.g., fall risk, activity precautions] (Include only if present)

Clinical Impression

[Concise synthesis of what improved and what did not, rationale for discharge at this time, expected trajectory with self-management or next services, and prognosis (good/fair/poor) with brief basis. If discharging despite remaining deficits, state why continued skilled therapy is not indicated. Limit to 3–5 sentences.]

Discharge Plan

Home Exercise Program: [Provided / Updated / Not provided]. [Core components and dosing (frequency, progression guidance)]. [Key precautions]. [Patient demonstrated competence: Yes / No]. (Reference separate HEP handout if provided.)

Follow-Up: [Timing and purpose for follow-up with referring provider]. [Referral recommendations if indicated]. [Indications for return to therapy or re-evaluation triggers].

Return Precautions / Red Flags: [Warning signs warranting urgent contact or emergency care] (Include only for higher-risk cases; tailor to diagnosis.)

Signature: [Author name, credentials] Date/Time Signed: [Date and time]

Attestation: I have reviewed the relevant treatment documentation for this episode of care and this Discharge Summary accurately reflects the patient's status and plan at discharge.