Discharge summary ot 2025

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  1. Click ‘Get Form’ to open the discharge summary ot in the editor.
  2. Begin by entering the patient's last name, first name, and middle initial in the designated fields.
  3. Fill in the number of visits, certification period, HICN, and date of discharge accurately.
  4. Document the therapist assistant's name if applicable, then proceed to summarize the patient's progress against established long-term goals (LTGs).
  5. For each LTG listed, indicate whether it was met by checking the appropriate box.
  6. Select reasons for discharge by checking all that apply and provide explanations where necessary.
  7. Complete additional comments and recommendations for home programs, medical follow-ups, referrals, or other notes as needed.
  8. Finally, ensure that the therapist’s name and credentials are printed clearly before signing and dating the report.

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As with your clients progress notes, your discharge summary should include certain information that sums up your work together, such as: Client information. Diagnosis both their initial diagnosis and their diagnosis at the time of discharge. Current symptoms. Discharge date. Services provided. Treatment summary.
Discharge planning is the development of a personalised plan that assesses a patients health and social care needs prior to them leaving hospital, to support the timely transition between hospital and home or another setting and improve the organisation of post‐discharge services.
Discharge goals Know when they will be going home and what they have to do on the day of discharge. To feel safe, that is, to feel like they are ready to go home (or transition elsewhere) Have the information needed for going home and caring for themselves in the days after discharge.
OT discharge planning can include pre-admission and post discharge assessments for a range of needs. The assessment is an opportunity to identify and respond to changes in function and health that impact on safety, mobility, and independence.
The National Standard for Patient Discharge Summary Information consists of the seven groups of headings: Patient details, Primary care healthcare professional details, Admission and discharge information, Clinical information, Medication information, Follow up and future management, and Person completing discharge
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Responsibilities specific to Discharge Planning includes assessment, identification of specific needs, and social service intervention or referral while in the acute setting. Awareness of services available to patients and their families are an important part of this assessment.

discharge summary example