Speech-Language Pathology Discharge Summary (Therapy Episode)

Patient Name: [Patient full name]

MRN: [Medical record number]

DOB: [Date of birth]

Date of Discharge: [Discharge date]

Setting/Location: [Outpatient clinic / Home health / SNF Part B / Other]

Rendering Clinician: [Clinician name, credentials]

Referring/Ordering Provider: [Provider name, credentials]

Primary Medical Diagnosis: [Primary diagnosis]

SLP Treatment Diagnosis: [SLP diagnosis]

Start of Care Date: [SOC date]

Last Progress Report Date: [Most recent progress report date]

Reporting Period: [Last progress report date] to [Discharge date]

Total Visits in Episode: [Number of visits]

Visits Since Last Progress Report: [Number of visits]

Discharge Snapshot: [1–2 sentence summary of discharge status, overall goal attainment, and disposition]

Reason for Discharge

Discharge Type: [Planned / Unplanned]

Primary Reason: [Goals met / Maximum benefit achieved / Plateau despite skilled modifications / Transition of care / Patient or caregiver request / Non-attendance / Change in medical status / Authorization limitation]

Disposition: [Home with home program / Transition to outpatient / Transition to home health / Transition to higher level of care / Other]

(If discharge reason cannot be determined due to lost contact, document outreach attempts with dates, modalities, and outcomes.)

Episode Focus

• [Primary SLP problem area addressed] (Include only domains addressed in this episode.)
• [Additional SLP problem areas as applicable]
• [Key contextual factors impacting outcomes, if relevant: caregiver availability, comorbidities, communication barriers]

Services Provided Since Last Progress Report

Actual Frequency and Dosage Delivered: [Sessions per week, duration per session, total sessions in reporting period] (State what was delivered, not what was authorized.)

• Language/Aphasia Interventions: [Approaches and targets addressed]
• Cognitive-Communication Interventions: [Approaches and targets addressed]
• Motor Speech/Voice Interventions: [Approaches and targets addressed]
• Dysphagia Interventions: [Compensatory and rehabilitative methods, diet trials] (Only include if swallowing was addressed.)
• AAC/Communication Supports: [Device or low-tech supports; programming or feature adjustments]
• Skilled Modifications Made: [Task grading, cueing hierarchy changes, strategy refinements, device adjustments with rationale]

(If unplanned discharge and detailed records unavailable, note that summary is based on available treatment documentation.)

Status at Discharge

Patient/Caregiver Perception of Change: [Per patient report: perceived changes] [Per caregiver report: perceived changes] (Clearly attribute to reporter.)

• Standardized Measures: [Measure name] — [Score] ([Interpretation], [Date administered])
• Functional Communication Performance: [Activity and participation description with assistance level, cueing level, accuracy, intelligibility as applicable]
• Swallowing Status: [Diet texture and liquid level tolerated, strategies required, signs/symptoms, instrumental findings if available] (Only include if dysphagia was addressed.)
• Safety Status: [Safety abilities and risks with documented assessment basis] (Do not infer safety without documented assessment.)
• Remaining Limitations: [Ongoing activity limitations and impact on participation in life roles]

(If discharge measures not completed due to unplanned discharge, document last known status with date.)

Goal Outcomes

Goal (functional wording)	Baseline	Discharge Status	Outcome
[Functional goal statement]	[Baseline data or "Baseline not available"]	[Status at discharge with assistance/cueing/accuracy]	[Met / Partially Met / Not Met / Discontinued]
[Functional goal statement]	[Baseline data or "Baseline not available"]	[Status at discharge]	[Met / Partially Met / Not Met / Discontinued]
[Functional goal statement]	[Baseline data or "Baseline not available"]	[Status at discharge]	[Met / Partially Met / Not Met / Discontinued]

(Add or remove rows as needed. State explicitly if baseline data is missing.)

Narrative Synthesis: [Summary of overall progress, barriers encountered, facilitators of progress, and implications for continued needs. Note any goal changes since last progress report with rationale.]

Education and Training Provided

• Topics Trained: [Strategies, cueing hierarchies, communication supports, diet modifications, device use, safety precautions]
• Methods of Instruction: [Demonstration / Teach-back / Verbal instruction / Written materials / Video resources]
• Learner and Competency: [Patient / Caregiver / Staff] — [Description of understanding demonstrated and remaining training needs]
• Materials Provided: [Home program sheets, device guides, handouts, log sheets]

Home Program

(If transitioning to another facility, replace with carryover plan for receiving staff. If not reviewed due to unplanned discharge, reference last issued program with date.)

• Activity: [Description] — [Frequency] x [Duration]
  Setup: [Requirements] | Stop if: [Warning signs] | Adherence supports: [Caregiver cueing, reminders, tracking]
• Activity: [Description] — [Frequency] x [Duration]
  Setup: [Requirements] | Stop if: [Warning signs] | Adherence supports: [Supports]
• Daily Strategies: [Communication or swallowing strategies with contexts for use]

Recommendations

(Prioritize by clinical risk and time sensitivity. Link each recommendation to documented findings.)

• SLP Follow-up: [No further SLP indicated / Re-evaluation in (timeframe) / Return to therapy if (specific triggers)]
• Referrals: [Audiology / ENT / Neurology / OT / PT / Dietitian / Neuropsychology / Primary care] — [Rationale tied to findings]
• Equipment/AAC: [Device or low-tech supports; procurement and training plan]
• Dysphagia Recommendations: [Diet texture] and [Liquid level] — [Rationale]. Instrumental evaluation: [Indicated / Not indicated] — [Criterion]. Escalation guidance: [Signs requiring immediate medical attention and contact instructions] (Only include if swallowing was addressed.)
• Safety/Environmental Modifications: [Recommendations tied to observed risks]

(Omit sections or bullets that do not apply. Distinguish clinician observations from patient/caregiver reports throughout.)