Recreational Therapy Discharge Summary

Date: [Discharge date]

Setting/Service Line: [Care setting/service line]

Episode Dates: [RT evaluation date – discharge date]

Total Sessions: [Total sessions and modality breakdown] (Include individual/group breakdown; note telehealth/hybrid only if applicable.)

Discharge Context

Reason for discharge: [goals met / goals partially met / plateau / transition to different level of care / patient or family request / non-attendance / medical change / psychiatric change / administrative] (Select primary reason and briefly elaborate.)

Discharge disposition: [Disposition relevant to leisure planning] (Include only if known and relevant to leisure recommendations.)

Unplanned discharge details: [Trigger event and portions of discharge assessment/teaching not completed] (Include only if unplanned; otherwise omit this field.)

Treatment Focus and Relevant Factors

[Brief summary of RT treatment focus areas] (E.g., leisure education, coping via leisure, community reintegration, social participation, adapted leisure skills; include only those actually addressed.)

• Key impairments/barriers affecting leisure participation: [Functional, cognitive, psychosocial, environmental, or social barriers]
• Strengths/motivators: [Interests, values, supports, personal strengths]
• Precautions impacting leisure recommendations or safety: [Relevant precautions or restrictions] (Include only if directly impacts leisure or safety guidance; otherwise omit.)

Course of Recreational Therapy Services

[Narrative summary of intervention approach, frequency, duration, and intensity as delivered]

[Interventions provided and clinical rationale] (E.g., leisure education, skill training, community resource navigation, behavioral activation, leisure counseling. Emphasize why interventions were selected or adapted.)

[Patient participation and response] (Engagement level, tolerance, barriers encountered, and observed response to interventions.)

Outcomes at Discharge

(Organize by goal/problem area. For unplanned discharges, do not assume goals were met; use "Unable to assess" with brief reason when appropriate.)

[Goal/Problem Area 1]

• Goal statement: [Goal statement as written in plan of care]
• Baseline status: [Baseline performance/measure with date and source]
• Discharge status: [Current performance/measure with date and source]
• Goal status: [Met / Partially Met / Not Met / Unable to Assess]
• Evidence supporting status: [Objective measure, observed performance, or patient report with date/source]
• If not met, partially met, or unable to assess: [Brief reason and disposition] (Omit if goal met.)

[Goal/Problem Area 2]

• Goal statement: [Goal statement]
• Baseline status: [Baseline with date/source]
• Discharge status: [Current with date/source]
• Goal status: [Met / Partially Met / Not Met / Unable to Assess]
• Evidence supporting status: [Evidence]
• If not met, partially met, or unable to assess: [Reason and disposition] (Omit if goal met.)

(Add additional goal/problem sections as needed.)

Standardized Outcome Measures

(Include only if standardized measures were used; otherwise omit this subsection.)

• [Instrument name]: [Date(s) administered] — [Score(s)] — [Direction of change] — [Plain-language interpretation]

Synthesis: [2–4 sentence summary of current leisure participation capacity, social participation, community reintegration readiness, coping skill use, and support needs] (Focus on change over time and handoff-critical information.)

Patient and Caregiver Education

(Include this section only if education was provided; omit entirely otherwise.)

• Recipient(s): [Patient / Family / Caregiver / Staff] (List all who received instruction.)
• Topics taught: [Topics covered]
• Methods: [Verbal / Written materials / Demonstration / Guided practice]
• Evaluation of learning: [Teach-back content correctly stated / Return demonstration performed / Observed independent use] (Do not infer understanding without documented evaluation method.)
• Materials provided: [List materials provided, or "None"]
• Barriers/incomplete education: [If education declined or incomplete, document barrier and whether materials were offered] (Omit if education completed without barriers.)

Discharge Leisure Plan and Community Resources

[Personalized, actionable leisure plan summary]

• Activities: [What activities] — Where: [Locations] — With whom: [Alone / peers / family / group] — Frequency: [How often]
• Adaptations/equipment: [Adaptations or devices needed and whether obtained]
• Environmental supports: [Home/community supports, prompts, supervision level]
• Community resources: [Resource name and contact] — [information provided / referral arranged / intake completed]
• Barriers and mitigation: [Transportation / cost / accessibility / supervision needs] — [Strategies discussed]

Safety Considerations

(Include only when safety risks are relevant to leisure participation or community transitions; otherwise omit this section.)

• Specific risks: [Fall risk during activities / wandering or elopement / cognitive safety deficits / behavioral triggers in groups or community settings]
• Safety strategies recommended: [Supervision level / environmental modifications / activity restrictions]
• Safety education provided: [Topic taught and method] — Understanding evaluated by: [Teach-back / return demonstration / observation]

Follow-up Recommendations

• RT-specific follow-up: [Outpatient RT / community reintegration program / adaptive recreation / peer support resources]
• Referrals to other disciplines: [Disciplines and purpose]
• Coordination completed: [Handoff to receiving facility / communication with case management / family involvement]
• Recommended but not arranged: [Service and reason: patient declined / eligibility pending / insurance issues] (Omit if all recommendations were arranged.)

(Use "Unknown: [brief reason]" for required fields when information is unavailable. Omit sections not performed rather than leaving blank.)

Author: [Name], [Credentials (e.g., CTRS)]

Date Signed: [Date]