Occupational Therapy Discharge Summary Template and Examples

Updated: April 25, 2024

Your patient is ready for discharge, and now it’s time to prepare a comprehensive summary of the care you’ve provided. This crucial document outlines the entire course of treatment and sets the stage for any future care needed.

This article provides practical tips for writing efficient and effective discharge summaries. We'll also explore how using templates can streamline your documentation process and highlight the benefits of integrating tools like TextExpander to be more productive.

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How to Write an Effective Occupational Therapy Discharge Summary

Creating an effective discharge summary is more than just documenting the last session. It involves capturing the entire therapeutic journey of your patient. Here are key points to consider:

  • Summarize the Therapy Goals and Outcomes: Clearly state what the therapy aimed to address and the progress made towards these goals.
  • Detail the Treatment Provided: Include types of interventions used and their frequency, highlighting any adaptations made to meet specific needs.
  • Evaluate Patient’s Current Status: Assess the patient’s functional levels compared to the initial evaluation.
  • Recommendations for Future OT: Offer clear guidance on any continuing care, follow-up treatments, or home modifications needed to support the patient’s ongoing recovery or adaptation.

Benefits of Using Discharge Summary Templates

Utilizing templates for discharge summaries can vastly improve your efficiency and consistency in documentation. Here’s how:

  • Consistency in Communication: Templates help standardize the information shared with other healthcare providers, ensuring nothing vital is overlooked.
  • Time Efficiency: Templates streamline the writing process, allowing more time for patient care.
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  • Critical Elements: Well-designed templates ensure all essential elements are covered, including patient details, therapy outcomes, and follow-up care recommendations.

How TextExpander Can Help

TextExpander is a tool that can improve the way documentations are managed. TextExpander helps save time, reduce errors, and maintain document consistency by creating shortcuts for commonly used text snippets in discharge summaries.

Occupational Therapy Discharge Summary Template and Examples

Discharge Summary Template Copy Snippet Copied!

Patient Details: Name, ID, Date of Birth

Therapy Duration: Start and End Dates

Goals and Outcomes: Initially set goals and the outcomes achieved

Interventions Used: Types of therapeutic interventions applied

Final Assessment: Patient’s functional status at discharge

Discharge Recommendations: Specific recommendations for continued care or activities

Examples of Occupational Therapy Discharge Summaries

Example 1: Post-Stroke Rehabilitation

Patient Details: John Doe, ID 123456, DOB 01/01/1960

Therapy Duration: January 10 to April 24

Goals and Outcomes: Improve right arm mobility; achieved 75% improvement in range of motion

Interventions Used: Manual therapy, therapeutic exercises, daily living skills training

Final Assessment: Significant improvement in daily functions, minor assistance needed

Discharge Recommendations: Continue with home exercises, follow-up in 6 weeks

Example 2: Recovery from Hip Replacement

Patient Details: Jane Smith, ID 654321, DOB 02/02/1970

Therapy Duration: February 15 to May 20

Goals and Outcomes: Achieve independent mobility; fully achieved goal

Interventions Used: Gait training, strength training, pain management

Final Assessment: Patient is independently mobile with no discomfort

Discharge Recommendations: No follow-up required, patient advised to avoid high-impact activities

Example 3: Pediatric Developmental Delays

Patient Details: Lucy Brown, ID 789012, DOB 03/03/2010

Therapy Duration: March 01 to June 30

Goals and Outcomes: Enhance fine motor skills; improved hand coordination

Interventions Used: Sensory integration therapy, fine motor play activities

Final Assessment: Improved coordination, continues to need minor support

Discharge Recommendations: Continue with occupational therapy in a school setting, reassess in one year

What is TextExpander

With TextExpander, you can store and quickly expand full email templates, Slack messages, and more anywhere you type. That means no more misspellings, no need to memorize complex instructions, or type the same things over and over again. See for yourself here:

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With TextExpander, you can store and quickly expand full email templates, email addresses, and more anywhere you type. That means you’ll never have to misspell, memorize, or type the same things over and over again.

Patient Details: Name, ID, Date of Birth <br> <br>Therapy Duration: Start and End Dates <br> <br>Goals and Outcomes: Initially set goals and the outcomes achieved <br> <br>Interventions Used: Types of therapeutic interventions applied <br> <br>Final Assessment: Patient's functional status at discharge <br> <br>Discharge Recommendations: Specific recommendations for continued care or activities <br> <br>Examples of Occupational Therapy Discharge Summaries
Patient Details: John Doe, ID 123456, DOB 01/01/1960 <br> <br>Therapy Duration: January 10 to April 24 <br> <br>Goals and Outcomes: Improve right arm mobility; achieved 75% improvement in range of motion <br> <br>Interventions Used: Manual therapy, therapeutic exercises, daily living skills training <br> <br>Final Assessment: Significant improvement in daily functions, minor assistance needed <br> <br>Discharge Recommendations: Continue with home exercises, follow-up in 6 weeks
Patient Details: Jane Smith, ID 654321, DOB 02/02/1970 <br> <br>Therapy Duration: February 15 to May 20 <br> <br>Goals and Outcomes: Achieve independent mobility; fully achieved goal <br> <br>Interventions Used: Gait training, strength training, pain management <br> <br>Final Assessment: Patient is independently mobile with no discomfort <br> <br>Discharge Recommendations: No follow-up required, patient advised to avoid high-impact activities
Patient Details: Lucy Brown, ID 789012, DOB 03/03/2010 <br> <br>Therapy Duration: March 01 to June 30 <br> <br>Goals and Outcomes: Enhance fine motor skills; improved hand coordination <br> <br>Interventions Used: Sensory integration therapy, fine motor play activities <br> <br>Final Assessment: Improved coordination, continues to need minor support <br> <br>Discharge Recommendations: Continue with occupational therapy in a school setting, reassess in one year

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With TextExpander, you can store and quickly expand snippets anywhere you type. That means you'll never have to misspell, memorize, or type the same things over and over, ever again.

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