Completing a Discharge Summary

**ALL DOCUMENTATION MUST BE COMPLETED IN ORDER TO DISCHARGE A CASE**

To Discharge a patient, go to the Documentation tab of the patient's case

Click Update POC or DS under Therapist Tasks

If the Update POC or DS is not a task under Therapist Tasks you can click Discharge Summary above the Case Work Queue section of the Documentation tab

This will open/ create a Discharge Summary for the patient

In the Discharge Summary header you'll see:

Date of the Discharge Summary
Patient First & Last name, Date of Birth, and Age
Referring Physician
Attended Visits
Cancellations (Cancelled Visits)
Diagnosis associated with the case

You can change the date of the Discharge Summary in the Date field by typing in the appropriate date. **Note: This can only be changed on initial completion of the Discharge Summary. (e.g. Clinician verbally discharged the patient at appointment on 12/14/2020 but did not complete discharge summary until 12/16/2020. The Date of the Discharge Summary can be changed to 12/14/2020 on initial completion on 12/16/2020 to reflect the date of discharge)

You can change the referring physician before completing the document as well if needed, by clicking and typing in the Referring Physician field

The Discharge Summary is broken into 6 sections:

*Denotes a required piece of information

Treatment
Subjective*
Objective/ Problems & Goals*
Assessment*
Discharge Plan*
Signature*

**Note: If patient did not keep or cancelled their Discharge appointment without rescheduling you can open the Discharge Summary and select 'Patient did NOT keep Discharge Appointment. Unable to take measurements' at the bottom of the Objective/ Problems & Goals section.

Treatment

In the Treatment section of the Discharge Summary you'll see the:

First Visit
Last Visit (Most recent 'acknowledged' visit)
Treatment Summary (Charge descriptions from first visit to last visit)
Comments (Optional)

Review the Treatment section of the Discharge Summary and enter any additional comments in the Comments field.

Subjective

Enter in Patient Comments related to patient's progress & treatment

Assessment

Enter the Discharge Prognosis

Enter your assessment in the Therapist Assessment section

Discharge Plan

Select the Discharge Reason(s) from the Discharge Plan list (Hint: Can select one or more reasons)

**Note: If selecting 'Other' please specify 'Other' reason in the text field provided.

Enter any Additional Recommendations in the Additional Recommendations text box (Optional)

Signature

Click Save Changes to ensure all sections of the document are saved

The message of 'Document has been saved' will display ensuring that all sections were saved

Enter PIN and click Sign and Submit