Rehabilitation Psychology Discharge Summary

Patient: [Patient name or identifier]

DOB: [MM/DD/YYYY] Episode Dates: [Start date – End date] Setting: [inpatient rehabilitation / inpatient consult / outpatient / day rehab / SNF / LTACH / home health]

Discharge Disposition: [home / SNF / inpatient rehab / outpatient continuation / other]

Referring Provider: [Name, role, service]

Primary Rehabilitation Diagnosis: [ICD code and condition label]

Author/Credentials: [Name, degree(s), license]

Executive Summary

[Concise 5–8 line snapshot: why rehabilitation psychology was involved; core formulation in functional/participation terms—primary barriers and facilitators to engagement; key interventions delivered; what changed; ongoing barriers/risks; top discharge recommendations]

• [Critical takeaway #1: highest-impact recommendation or risk consideration]
• [Critical takeaway #2: participation/engagement strategy for next team]
• [Critical takeaway #3: caregiver or environmental support needed]
• [Critical takeaway #4: follow-up timing and responsible party]
• [Critical takeaway #5: contingency/safety instruction] (Only include if relevant)

Reason for Referral

[Referral question and context] (Include the referrer's question in quotes if available; summarize patient-stated goals or concerns; describe baseline functional impact on rehabilitation participation—e.g., reduced engagement, therapy refusal, agitation, avoidance. Add concise biopsychosocial factors relevant to participation. Attribute sources when relevant—patient, caregiver, staff, chart.)

• [Primary concern #1 affecting participation/safety]
• [Primary concern #2 affecting participation/safety]
• [Primary concern #3 affecting participation/safety]
• [Communication supports needed: interpreter, aphasia strategies, cognitive supports] (Only include if applicable)

Episode of Care Overview

[Number of contacts, duration, and frequency] (Example: "8 contacts over 3 weeks, approximately 2x/week") [Service type: consult / brief intervention / psychotherapy / caregiver sessions / interdisciplinary co-treatment] [Family meetings, team conferences, or care plan huddles if applicable]

• Interventions Delivered:
  • [Engagement and adherence strategies: motivational enhancement, contingency strategies, structured goal-setting]
  • [Behavioral/activation approaches: behavioral activation with graded activity scheduling, energy pacing]
  • [Anxiety/fear reduction: graded exposure for fear of falling, relaxation/diaphragmatic breathing]
  • [Cognitive/communication supports: external memory aids, cueing hierarchies, environmental simplification]
  • [Pain/sleep/fatigue management: CBT-I components, sleep hygiene, pain coping skills]
  • [Caregiver coaching/education: cueing strategies, reinforcement plans, communication strategies]
  • [Interdisciplinary coordination: team conference participation, behavioral plan development]
  (Include only intervention domains that apply)

Key Clinical Findings

(Summarize only domains assessed that inform discharge planning; use person-centered, function-oriented language. Omit domains not assessed rather than documenting negative findings. Attribute information sources when relevant.)

Emotional/Behavioral Status: [Mood, anxiety, irritability, behavioral activation/inertia, agitation; how these affect therapy participation/safety]

Cognitive Considerations: [Attention, processing speed, memory, executive function, insight/anosognosia; impacts on learning, carryover, safety, decision-making]

Adjustment and Coping: [Acceptance, self-efficacy, identity changes, grief/adjustment to disability; facilitators/barriers to rehabilitation goals]

Adherence and Engagement Patterns: [Attendance/participation consistency, triggers for refusal or avoidance, effective prompts/reinforcers]

Pain/Sleep/Fatigue: [Pain characteristics, coping strategies, sleep quality, fatigue patterns; interaction with therapy scheduling and stamina]

Caregiver Dynamics and Needs: [Caregiver availability, capacity, training needs, stress; coordination needs for safe discharge]

Social Determinants/Context: [Housing, transportation, financial constraints, work/school obligations; implications for access, adherence, safety]

Strengths/Protective Factors: [Personal strengths, coping skills, support network, motivation, prior routines; how to leverage post-discharge]

Progress and Outcomes

(List problems in order of impact on safety and function. For each, document baseline status, interventions, objective response/progress, current status at discharge, and carry-forward plan with responsible party.)

[Problem 1: Functional/participation-focused label]

• Baseline: [Initial status and functional impact; include objective indicators if available]
• Interventions: [Named interventions applied during episode]
• Response/Progress: [Objective changes; include frequency/percentage/ratings where available]
• Current Status at Discharge: [Functional participation and remaining barriers/risks]
• Carry-Forward Plan: [Next responsible provider/service, timeframe, specific strategy to continue or modify]
• Outcome Measures: [Measure name] — [Baseline score] → [Discharge score] ([Interpretation]) (Only include if standardized measures were used; if attempted but invalid, state why)

[Problem 2: Functional/participation-focused label]

• Baseline: [Initial status]
• Interventions: [Interventions delivered]
• Response/Progress: [Change observed]
• Current Status at Discharge: [Status now]
• Carry-Forward Plan: [Responsible party and timing]
• Outcome Measures: [As applicable]

(Add additional problems as needed. Close all loops—if a goal or intervention is listed, specify disposition and who is responsible post-discharge.)

Risk Assessment and Safety Planning

(Include this section only if risk-relevant content occurred during the episode—suicidal ideation, self-harm, violence risk, severe psychiatric symptoms, abuse/neglect concerns, high-risk cognitive impairment affecting safety. Otherwise omit entirely.)

• Risk Domains Assessed: [suicidal ideation / self-harm / violence risk / severe psychiatric symptoms / abuse/neglect / high-risk cognitive impairment]
• Current Risk Level at Discharge: [low / moderate / high] (State level explicitly; do not use ambiguous phrasing)
• Key Risk Factors: [Specific, relevant factors]
• Protective Factors: [Specific, relevant factors]
• Lethal Means/Environmental Safety: [Counseling provided; steps taken; responsible person] (Only include if applicable)
• Safety Plan: [created / reviewed / updated / declined]; [location of plan]; [shared with: names/roles]
• Escalation Instructions: [Crisis line], [ED threshold], [who to contact first], [after-hours instructions]
• Screening Limitations: [If required screening not completed, reason and mitigation plan] (Only include if applicable)

Discharge Recommendations

(Provide actionable, prioritized items with timeframes and responsible party. Organize by category.)

• Follow-up Level of Care:
  • Referrals placed: [Service, timeframe, provider/clinic]
  • Referrals recommended: [Service, timeframe, responsible party to place]
  • Patient declined: [Service and rationale if stated] (Only include if applicable)
• Rehabilitation Participation Strategies: [Behavioral approaches for adherence, pacing, graded activity, reinforcement plans, optimal scheduling]
• Cognitive/Communication Supports at Home: [Memory aids, cueing strategies, environmental modifications, written routines]
• Sleep and Pain Management: [CBT-I elements, sleep hygiene, pain coping and activity pacing, medication coordination with prescriber]
• Caregiver and Family Needs: [Training topics, respite, support groups, community resources]
• School/Work/Community Reintegration: [Return-to-work/school plan, accommodations, transportation, community programs] (Only include if applicable)

Care Coordination

• Communications Completed: [Team conferences, family meetings, calls to outpatient providers; date; participants; outcome]
• Documents Provided/Shared: [Safety plan, coping plan, behavioral plan, educational handouts; recipients]
• Pending Items: [What is pending], [Responsible party], [Due date/trigger]

Clinical Impression / Diagnoses

• [Primary psychological diagnosis using DSM/ICD terminology]
• [Secondary diagnosis or condition impacting rehabilitation participation] (Only include if applicable)
• [Provisional / Rule-out diagnoses] (Clearly label as provisional or rule-out; only include if applicable)
• [If no formal diagnosis assigned, state "No formal diagnosis assigned" and describe focus of care]

Limitations

[Constraints affecting conclusions: limited visits, declined measures, language barrier, medical instability, sedation, acute delirium; what the receiving provider should assess next] (Include this section only if meaningful limitations exist; otherwise omit)

Signature

Author: [Name] Credentials: [Degree(s), license] Date/Time: [MM/DD/YYYY HH:MM]