Physical Therapy Discharge Summary Template and Examples

Updated: April 25, 2024

As a physical therapist, one of your responsibilities is to ensure that when a patient is ready for discharge, a comprehensive and clear summary is prepared. This note is crucial as it outlines the entire course of treatment and provides future care recommendations.

In this article, we'll provide valuable tips on how to craft great discharge summaries and discuss the benefits of using templates to streamline your documentation process. Using tools like TextExpander can significantly enhance your productivity by speeding up the rote tasks you complete multiple times per day – allowing you to spend more time with and thinking about patients.

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Crafting an Effective Physical Therapy Discharge Summary

Writing an effective discharge summary is key to ensuring continuous care and understanding of the patient’s therapy journey. Here are some tips to help you create a comprehensive and actionable discharge summary:

  • Start Early: Begin drafting the summary early in the treatment process and update it regularly to ensure completeness and accuracy.
  • Be Concise, but Thorough: Use bullet points for key information and brief paragraphs for necessary explanations, maintaining a balance between brevity and detail.
  • Highlight Outcomes and Recommendations: Clearly state physical therapy treatment goals, outcomes, and specific follow-up care recommendations to ensure continuity of care.
  • Review for Accuracy: Double-check the summary for factual accuracy and coherence, possibly getting a peer review for complex cases.

Benefits of Using Physical Therapy Discharge Summary Templates

Using a discharge summary template can bring several benefits to your practice:

  • Consistency: Templates help maintain a standard format for all discharge documents.
  • Efficiency: Reduces the time taken to compile each summary from scratch.
  • Accuracy: Ensures all relevant information is included and nothing important is missed.
  • Professionalism: A well-structured document reflects the quality of care provided.

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.

Physical Therapy Discharge Summary Template

Discharge Summary Template Copy Snippet Copied!

1. Patient Information:
Name:
Date of Birth:
Case Number:
Date of Admission:
Date of Discharge:

2. Subjective:
Pain and Location:
Attendance:
Treatment Included:

3. Objective Findings:
(Details of objective measurements and findings during the final evaluation)

4. Treatment Provided:
(List of interventions and therapies provided)

5. Assessment & Goal Status:
(Assessment of goals met and progress made)

6. Plan:
(Recommendations for future care and any follow-up appointments)

Physical Therapy Discharge Summary Examples

Here are three examples of discharge summaries following the template provided:

Example 1:

1. Patient Information:
Name: John Doe
Date of Birth: January 1, 1980
Case Number: PT123456789
Date of Admission: March 1, 2023
Date of Discharge: June 15, 2023

2. Subjective: Patient reported reduced pain in the lower back, attended 90% of scheduled sessions, responded well to manual therapy and strengthening exercises.

3. Objective: Improved mobility and decreased pain as measured by the Visual Analog Scale.

4. Treatment Provided: Manual therapy, ultrasound treatment, supervised exercise regimen.

5. Assessment & Goal Status: Met most short-term goals regarding pain reduction and mobility improvement.

6. Plan: Recommended continued physical activity and a follow-up after six weeks.

Example 2:

1. Patient Information:
Name: Mary Smith
Date of Birth: April 10, 1975
Case Number: PT987654321
Date of Admission: January 20, 2023
Date of Discharge: May 20, 2023

2. Subjective: Consistent shoulder pain, good attendance, included electrotherapy and heat treatment.

3. Objective: Increased range of motion and strength in the shoulder.

4. Treatment Provided: Combination of electrotherapy, heat treatments, and targeted exercises.

5. Assessment & Goal Status: Achieved goals related to pain management and functional use of the arm.

6. Plan: Patient was advised to join a community gym and continue exercises, with periodic evaluations every two months.

Example 3:

1. Patient Information:
Name: Alex Johnson
Date of Birth: July 22, 1985
Case Number: PT456789123
Date of Admission: April 10, 2023
Date of Discharge: July 10, 2023

2. Subjective: Mild knee pain, missed a few sessions due to personal commitments, involved aquatic therapy.

3. Objective: Slight improvement in knee stability and strength.

4. Treatment Provided: Aquatic therapy sessions supplemented with home exercises.

5. Assessment & Goal Status: Partial achievement of stability goals; moderate improvement in pain.

6. Plan: Continue with the home exercise program and re-evaluate in three months.
These detailed examples should give a clearer picture of how to document patient information alongside the summary of their treatment and progress, adhering to a standardized format for clarity and continuity of care.

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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.

1. Patient Information: <br>Name: <br>Date of Birth: <br>Case Number: <br>Date of Admission: <br>Date of Discharge: <br> <br>2. Subjective: <br>Pain and Location: <br>Attendance: <br>Treatment Included: <br> <br>3. Objective Findings: <br>(Details of objective measurements and findings during the final evaluation) <br> <br>4. Treatment Provided: <br>(List of interventions and therapies provided) <br> <br>5. Assessment & Goal Status: <br>(Assessment of goals met and progress made) <br> <br>6. Plan: <br>(Recommendations for future care and any follow-up appointments)
1. Patient Information: <br>Name: John Doe <br>Date of Birth: January 1, 1980 <br>Case Number: PT123456789 <br>Date of Admission: March 1, 2023 <br>Date of Discharge: June 15, 2023 <br> <br>2. Subjective: Patient reported reduced pain in the lower back, attended 90% of scheduled sessions, responded well to manual therapy and strengthening exercises. <br> <br>3. Objective: Improved mobility and decreased pain as measured by the Visual Analog Scale. <br> <br>4. Treatment Provided: Manual therapy, ultrasound treatment, supervised exercise regimen. <br> <br>5. Assessment & Goal Status: Met most short-term goals regarding pain reduction and mobility improvement. <br> <br>6. Plan: Recommended continued physical activity and a follow-up after six weeks.
1. Patient Information: <br>Name: Mary Smith <br>Date of Birth: April 10, 1975 <br>Case Number: PT987654321 <br>Date of Admission: January 20, 2023 <br>Date of Discharge: May 20, 2023 <br> <br>2. Subjective: Consistent shoulder pain, good attendance, included electrotherapy and heat treatment. <br> <br>3. Objective: Increased range of motion and strength in the shoulder. <br> <br>4. Treatment Provided: Combination of electrotherapy, heat treatments, and targeted exercises. <br> <br>5. Assessment & Goal Status: Achieved goals related to pain management and functional use of the arm. <br> <br>6. Plan: Patient was advised to join a community gym and continue exercises, with periodic evaluations every two months.
1. Patient Information: <br>Name: Alex Johnson <br>Date of Birth: July 22, 1985 <br>Case Number: PT456789123 <br>Date of Admission: April 10, 2023 <br>Date of Discharge: July 10, 2023 <br> <br>2. Subjective: Mild knee pain, missed a few sessions due to personal commitments, involved aquatic therapy. <br> <br>3. Objective: Slight improvement in knee stability and strength. <br> <br>4. Treatment Provided: Aquatic therapy sessions supplemented with home exercises. <br> <br>5. Assessment & Goal Status: Partial achievement of stability goals; moderate improvement in pain. <br> <br>6. Plan: Continue with the home exercise program and re-evaluate in three months. <br>These detailed examples should give a clearer picture of how to document patient information alongside the summary of their treatment and progress, adhering to a standardized format for clarity and continuity of care.

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