Discharge/Transition Plans

when do you write a discharge/transition note?

client returning home, client completed goals and does not need TR anymore, client transitioning to a lower level of care, lack of participation or refusal, self-termination, medical leave

what is in a typical plan

an overview of pt. medical and leisure history. overview of TR services they received. achievement of goals and outcomes (assessment data). areas that still need improvement and remaining barriers. also future recommendations

writing style

must be clear and concise. may use a specific form (you just fill it in) or be written in a narrative style

importance

connects pt. with resources in community, helps to educate pt., minimizes “relapse”, assists with community reintegration, helps the pt. maintain goals that were achieved as a result of TR services, helps to show importance of our field!

community reintegration

do your research on special rec associations in community (ex: wheelchair sports leagues), support groups within the community, accessible recreation/outdoor programs and facilities, national support organizations, volunteer opportunities for PWD, adaptive equipment (where to rent or purchase)

VATS

Virginia Assistive Technology System. provides free or discounted adaptive technology