Discharge Summaries

Flashcards about Discharge Summaries in Occupational Therapy

Discharge Summaries

In Texas, occupational therapy assistants do not write these.

Occupational Therapist

The only professional that has the authority to discharge clients from occupational therapy services.

Occupational Therapist's Role

Determines if goals were met and signs the discharge documentation.

OT role in discharge

Review any information from assistants, determine if goals were met, and make recommendations for any further needs of the client

Information in Discharge Summary

Type of treatment, home program independence, and other instructions.

Discharge Summary Details

Equipment sold to patient and written instructions given.

Instruction Information

Patient, family, or both; method of instruction verbal, written, or demonstration.

Expected Functioning Level

Demonstrate activity and state precautions.

Referral Information

Referral to home health agency or other professional, if applicable.

Treatment Frequency

Number of times the patient was seen in therapy.

Session Cancellations

Skipped or canceled treatment sessions.

Treatment Holds

Instances when the patient was not seen and the reason.

Discharge Destination

The location to where the patient is discharged.

Reason for Discharge

Goals achieved, transfer, patient request, etc.

Follow-Up Recommendations

Recommendations for follow-up treatment or care.

Examples of Treatment

ADLs, Functional mobility, standing balance, strengthening and endurance

Reason for Refusal of Treatment

Severe nausea

DCOT

Indicates discontinuation of occupational therapy services.

Example of Instruction

Home program and training with daughter.

Example of Discharge Outcome

Modified independent with all aspects of ADL, and all long term goals were met.