Creating a Discharge Summary in a client's profile Navigate to the client's Overview page. Click New>Assessment. Select Discharge Summary Note.

Example: “We have discharged Mrs Smith on regular oral (40mg OD) and we have requested an outpatient ultrasound of her renal tract which will be performed in the next few weeks. We will review Mrs Smith in the Cardiology Outpatient Clinic in 6 weeks time.

To continue to paraphrase the APTA's description: All discharge summaries should include patient response to treatment at the time of discharge and any follow-up plan, including recommendations and instructions regarding the home program if there is one, equipment provided, and so on.

What is in the discharge summary? Diagnosis at discharge. Detailed reasons for reasons for discharge (including progress toward treatment goals) Any risk factors at the time care ended. Referrals and resources of benefit to the client.

The discharge report must give a summary of everything the patient went through during the hospital admission period – physical findings, laboratory results, radiographic studies and so on.

The discharge summary is essentially the last opportunity the therapist has to justify the medical necessity of the treatments that were rendered during this episode of care. Therefore, additional relevant information may also be included in the report at the discretion of the therapist.

Ideally, this document should take no more than a few minutes for the receiving practitioner to review and ascertain the salient details of the hospitalization. In conveying this information, it can be helpful to think of the discharge summary as an admission H & P.