Occupational Therapy Discharge Summary Template

Q: What should be included in an OT discharge summary?

An OT discharge summary should include: reason for referral and diagnosis, initial functional status and ADL levels, treatment provided and interventions used, discharge functional status with comparison to initial, goals achieved and not achieved, home exercise program, equipment recommendations, follow-up recommendations, and caregiver training completed.

Q: When should an OT write a discharge summary?

An OT discharge summary should be written when the patient has achieved their goals, reached maximum benefit from skilled OT services, is being transferred to another facility, no longer requires skilled occupational therapy intervention, or when services are discontinued for any reason including patient request or non-compliance.

A complete OT discharge note template with functional outcomes, ADL status documentation, and recommendations. Free to use and customize for your practice.

What an OT Discharge Summary Includes

An occupational therapy discharge summary is a comprehensive document that summarizes the patient's entire episode of care. Unlike daily notes that focus on a single session, the discharge summary tells the complete story: where the patient started, what interventions were provided, and how their function improved.

A well-written OT discharge summary serves multiple purposes:

Communicates outcomes to referring physicians and other providers
Documents medical necessity for insurance and billing purposes
Provides continuity of care information for future providers
Creates a legal record of services provided and outcomes achieved
Guides the patient and caregivers on continued home programming

Essential Components of an OT Discharge Summary

Patient Demographics

Name, DOB, diagnosis, referral source, treating therapist, and dates of service (initial evaluation through discharge).

Reason for Referral

Why the patient was referred for OT services, primary diagnosis, and occupational performance concerns at the start of care.

Initial Functional Status

Baseline ADL/IADL performance levels, ROM/strength measurements, cognitive status, and standardized assessment scores at evaluation.

Treatment Summary

Overview of interventions provided, frequency and duration of services, and key therapeutic approaches used throughout the episode of care.

Discharge Functional Status

Current ADL/IADL performance levels, updated measurements, and comparison to initial status showing improvement or change.

Goals and Outcomes

List of all goals with status (met, partially met, not met), objective data supporting goal achievement, and explanation for unmet goals.

Discharge Recommendations

Home exercise program, equipment needs, safety precautions, activity modifications, and follow-up recommendations.

Caregiver Training

Education provided to family/caregivers, demonstrated competency with HEP and equipment, and ongoing support needs.

Documenting Functional Outcomes

The most critical element of an OT discharge summary is demonstrating functional change. Insurance companies, referring physicians, and quality reviewers want to see concrete evidence that therapy made a difference in the patient's daily life.

How to Document Functional Outcomes

Use objective measures: FIM scores, standardized assessments (COPM, AMPS), MMT, ROM
Compare initial to discharge status with specific data points
Describe changes in independence levels (Max A to Min A, supervision to independent)
Document specific ADL tasks improved (now dresses upper body independently)
Include patient-reported outcomes and satisfaction when appropriate

ADL Status Documentation

Activities of Daily Living (ADL) status is the cornerstone of OT discharge documentation. Use consistent terminology and independence levels throughout:

Level	Abbreviation	Description
Independent	I	Performs task safely without assistance or supervision
Modified Independent	Mod I	Performs task independently with adaptive equipment or extra time
Supervision	S	Requires standby assistance or verbal cueing only
Minimal Assistance	Min A	Patient performs 75% or more of the task
Moderate Assistance	Mod A	Patient performs 50-74% of the task
Maximum Assistance	Max A	Patient performs 25-49% of the task
Total Assistance	Total A	Patient performs less than 25% of the task
Dependent	D	Unable to participate; caregiver completes entire task

Complete OT Discharge Summary Template

Use this template as a starting point for your occupational therapy discharge summaries. Customize the sections to match your facility's requirements and documentation system.

OCCUPATIONAL THERAPY DISCHARGE SUMMARY

PATIENT INFORMATION

Patient Name: [Patient Name]
Date of Birth: [DOB]
Medical Record Number: [MRN]
Referring Physician: [Physician Name]
Primary Diagnosis: [ICD-10 Code and Description]
Secondary Diagnoses: [Additional diagnoses if applicable]

DATES OF SERVICE

Initial Evaluation Date: [Date]
Discharge Date: [Date]
Total Treatment Sessions: [Number]
Treatment Frequency: [e.g., 3x/week for 6 weeks]

REASON FOR REFERRAL

[Describe the reason for OT referral, including primary functional concerns, occupational performance deficits, and patient's goals at the start of care.]

INITIAL FUNCTIONAL STATUS

ADL Performance at Evaluation:
- Feeding: [Independence level]
- Grooming: [Independence level]
- Bathing: [Independence level]
- Dressing Upper Body: [Independence level]
- Dressing Lower Body: [Independence level]
- Toileting: [Independence level]
- Functional Transfers: [Independence level]

IADL Performance at Evaluation:
[List relevant IADLs and independence levels]

Physical/Motor Status at Evaluation:
- Upper Extremity ROM: [Key measurements]
- Upper Extremity Strength: [MMT grades or grip/pinch strength]
- Fine Motor Coordination: [Observations or standardized scores]

Cognitive/Perceptual Status at Evaluation:
[Relevant cognitive observations or assessment scores]

Standardized Assessment Scores at Evaluation:
[e.g., COPM, FIM scores, other standardized measures]

TREATMENT SUMMARY

Interventions Provided:
[List key intervention categories used throughout the episode of care, such as: ADL retraining, UE strengthening/ROM, fine motor coordination training, cognitive rehabilitation, compensatory strategy training, adaptive equipment training, caregiver education, home safety assessment, etc.]

Treatment Approaches:
[Describe therapeutic approaches: task-specific training, neuromuscular re-education, sensory integration, constraint-induced movement therapy, etc.]

DISCHARGE FUNCTIONAL STATUS

ADL Performance at Discharge:
- Feeding: [Level] (Initial: [Level])
- Grooming: [Level] (Initial: [Level])
- Bathing: [Level] (Initial: [Level])
- Dressing Upper Body: [Level] (Initial: [Level])
- Dressing Lower Body: [Level] (Initial: [Level])
- Toileting: [Level] (Initial: [Level])
- Functional Transfers: [Level] (Initial: [Level])

IADL Performance at Discharge:
[List with comparison to initial status]

Physical/Motor Status at Discharge:
- Upper Extremity ROM: [Measurements with change noted]
- Upper Extremity Strength: [Grades with change noted]
- Fine Motor Coordination: [Observations or scores with change noted]

Standardized Assessment Scores at Discharge:
[Scores with comparison to initial evaluation]

GOALS AND OUTCOMES

Goal 1: [State the goal]
Status: [Met / Partially Met / Not Met]
Outcome: [Describe specific outcome with objective data]

Goal 2: [State the goal]
Status: [Met / Partially Met / Not Met]
Outcome: [Describe specific outcome with objective data]

Goal 3: [State the goal]
Status: [Met / Partially Met / Not Met]
Outcome: [Describe specific outcome with objective data]

[Continue for all goals. For goals not met, explain barriers and reason for discharge despite unmet goals.]

REASON FOR DISCHARGE

[Select applicable: Goals met / Plateau in progress / Maximum benefit achieved / Patient request / Non-compliance / Transfer to another facility / Other - explain]

DISCHARGE RECOMMENDATIONS

Home Exercise Program:
[Describe HEP provided, frequency, and patient/caregiver understanding]

Equipment Recommendations:
[List DME/adaptive equipment recommended or already in place]

Activity Modifications:
[Describe any activity restrictions, precautions, or compensatory strategies to continue]

Follow-Up Recommendations:
[Future OT if needed, physician follow-up, other referrals]

CAREGIVER TRAINING

[Document education provided to family/caregivers, topics covered, demonstrated competency with HEP and equipment use, and any ongoing support needs identified.]

PATIENT/CAREGIVER EDUCATION

Patient/caregiver verbalized understanding of: [HEP, equipment use, safety precautions, activity modifications, signs/symptoms requiring medical attention]

THERAPIST SIGNATURE

Therapist Name: [Name, Credentials]
Signature: _________________________ Date: [Date]
License Number: [License #]

Pro Tip: Use Consistent Language

Use the same terminology and independence levels throughout the discharge summary that you used in the initial evaluation. This makes it easy for readers to identify changes and improvements at a glance.

OT Discharge Summary Example

Here is a filled-in example of an OT discharge summary for a patient recovering from a CVA. This example demonstrates how to document functional outcomes and compare initial to discharge status.

OCCUPATIONAL THERAPY DISCHARGE SUMMARY - Example

PATIENT INFORMATION

Patient Name: [Redacted for Privacy]
Date of Birth: [Redacted]
Referring Physician: Dr. [Redacted], PM&R
Primary Diagnosis: I63.9 - Cerebral infarction, unspecified (Left CVA with right hemiparesis)
Secondary Diagnoses: I10 - Essential hypertension, E11.9 - Type 2 diabetes

DATES OF SERVICE

Initial Evaluation Date: November 15, 2025
Discharge Date: January 20, 2026
Total Treatment Sessions: 24
Treatment Frequency: 3x/week for 8 weeks

REASON FOR REFERRAL

Patient referred for OT following left CVA resulting in right-sided hemiparesis. Primary concerns at referral included decreased independence in ADLs (dressing, bathing, grooming), reduced right upper extremity function impacting bilateral activities, and safety concerns with meal preparation and home management tasks. Patient's stated goal was to return to independent living in her apartment.

INITIAL FUNCTIONAL STATUS

ADL Performance at Evaluation:
- Feeding: Supervision (difficulty with R hand coordination, spillage)
- Grooming: Moderate Assistance (unable to manage brush/toothbrush with R hand)
- Bathing: Maximum Assistance (safety concerns, unable to manage lower body)
- Dressing Upper Body: Maximum Assistance (unable to manage R sleeve)
- Dressing Lower Body: Maximum Assistance (unable to reach feet safely)
- Toileting: Moderate Assistance (clothing management difficulties)
- Functional Transfers: Moderate Assistance (decreased R LE strength and balance)

Physical/Motor Status at Evaluation:
- R shoulder AROM: Flexion 70 degrees, Abduction 55 degrees
- R elbow AROM: Flexion 110 degrees, Extension -15 degrees
- R grip strength: 8 lbs (L: 45 lbs)
- R lateral pinch: 4 lbs
- Fine motor coordination: Severely impaired; unable to manipulate small objects
- Spasticity: MAS 2 R wrist/finger flexors

Cognitive Status: Alert and oriented x4, follows 2-step commands with occasional repetition, mild attention deficits noted during complex tasks.

TREATMENT SUMMARY

Interventions Provided:
- ADL retraining with emphasis on one-handed techniques and adaptive equipment use
- Right UE AROM/PROM and strengthening exercises
- Neuromuscular re-education for R UE function and coordination
- Fine motor coordination training with graduated activities
- Spasticity management including stretching and positioning
- Compensatory strategy training for bilateral tasks
- Adaptive equipment training (long-handled reacher, sock aid, built-up utensils)
- Home safety assessment and modification recommendations
- Caregiver education with daughter (primary support)

DISCHARGE FUNCTIONAL STATUS

ADL Performance at Discharge:
- Feeding: Independent with built-up utensils (Initial: Supervision)
- Grooming: Modified Independent with adaptive equipment (Initial: Mod A)
- Bathing: Supervision with shower chair and grab bars (Initial: Max A)
- Dressing Upper Body: Minimal Assistance for R sleeve only (Initial: Max A)
- Dressing Lower Body: Modified Independent with reacher/sock aid (Initial: Max A)
- Toileting: Modified Independent (Initial: Mod A)
- Functional Transfers: Supervision (Initial: Mod A)

Physical/Motor Status at Discharge:
- R shoulder AROM: Flexion 115 degrees (+45), Abduction 90 degrees (+35)
- R elbow AROM: Flexion 130 degrees (+20), Extension -5 degrees (+10)
- R grip strength: 22 lbs (+14 lbs improvement)
- R lateral pinch: 10 lbs (+6 lbs improvement)
- Fine motor coordination: Mildly impaired; able to manipulate medium objects with effort
- Spasticity: MAS 1+ R wrist/finger flexors (reduced from MAS 2)

GOALS AND OUTCOMES

Goal 1: Patient will complete upper body dressing with modified independence using adaptive techniques within 6 weeks.
Status: Partially Met
Outcome: Patient requires minimal assistance for R sleeve management only. Significant improvement from maximum assistance at evaluation. Patient independent with front-closure garments.

Goal 2: Patient will complete lower body dressing with modified independence using adaptive equipment within 8 weeks.
Status: Met
Outcome: Patient independently dons/doffs pants, socks, and shoes using reacher, sock aid, and elastic shoelaces. Demonstrates safe seated technique consistently.

Goal 3: Patient will demonstrate R grip strength of 20 lbs to support functional grasp within 8 weeks.
Status: Met
Outcome: R grip strength measured at 22 lbs at discharge, exceeding goal. Patient able to grasp and release medium-weight objects for functional tasks.

Goal 4: Patient will prepare simple cold meal independently using compensatory strategies within 8 weeks.
Status: Met
Outcome: Patient independently prepared sandwich and beverage in clinic kitchen using one-handed techniques, adaptive cutting board, and energy conservation strategies.

REASON FOR DISCHARGE

Patient has achieved maximum benefit from skilled OT services. Goals substantially met with patient demonstrating modified independence in ADLs. Patient has reached functional plateau with R UE recovery over past 2 weeks. Continued improvements expected with HEP but no longer require skilled intervention.

DISCHARGE RECOMMENDATIONS

Home Exercise Program: Written and illustrated HEP provided including R UE AROM exercises (3x daily), grip strengthening with therapy putty (2x daily), and fine motor activities. Patient and daughter demonstrate correct performance of all exercises.

Equipment in Place: Shower chair, grab bars (2), long-handled reacher, sock aid, elastic shoelaces, built-up utensils, adaptive cutting board, non-slip mat

Activity Modifications: Continue using one-handed techniques for bilateral tasks. Avoid carrying hot liquids in R hand until grip strength further improves. Use adaptive equipment consistently for safety.

Follow-Up: Recommend re-evaluation in 3 months if patient desires to work on R UE skilled use in bilateral activities. Continue outpatient PT for ambulation and balance. Follow up with neurologist as scheduled.

CAREGIVER TRAINING

Daughter attended 3 treatment sessions for caregiver training. Education provided on safe transfer techniques, HEP supervision, adaptive equipment use, and signs of CVA recurrence requiring immediate medical attention. Daughter demonstrates competency with all trained tasks and verbalizes understanding of safety precautions. Daughter will provide standby assistance for bathing and supervision for community outings initially.

This example demonstrates how to clearly document functional changes by comparing initial status to discharge status for each ADL and physical measure. The goal outcomes include specific objective data supporting whether each goal was met.

Tips for Writing OT Discharge Summaries

Writing effective discharge summaries takes practice. Here are proven strategies to make your documentation stronger, more efficient, and more useful for everyone who reads it.

1. Start with the End in Mind

Your discharge summary will be much easier to write if you document consistently throughout the episode of care. Use the same terminology, independence levels, and measurement methods from evaluation through discharge. This creates a clear thread that readers can follow.

2. Lead with Functional Outcomes

The most important information in a discharge summary is how the patient's function changed. Structure your summary so readers can quickly identify:

What could the patient NOT do at the start?
What CAN the patient do now?
What level of assistance or equipment is still needed?

3. Use Objective Data

Whenever possible, support your statements with measurable data. Instead of "patient improved significantly," write "grip strength improved from 8 lbs to 22 lbs." Objective measurements are more credible and easier for other providers to interpret.

Types of Objective Data to Include

Standardized assessment scores (FIM, COPM, AMPS)
ROM measurements in degrees
Strength measurements (MMT grades, grip/pinch in pounds)
Independence levels using consistent terminology
Time to complete functional tasks (if relevant)
Distance or repetitions for physical measures

4. Explain Unmet Goals

Not every goal will be met, and that's okay. When a goal isn't achieved, explain why. Was there a medical complication? Did the patient's priorities change? Did the patient reach a plateau? This context helps readers understand the situation and is important for insurance justification.

5. Make Recommendations Actionable

Discharge recommendations should be specific enough that the patient and caregivers know exactly what to do. Instead of "continue home exercises," specify "complete R UE stretching program 3 times daily as demonstrated and documented in attached HEP."

6. Document Caregiver Competency

If caregivers will be assisting the patient, document what training was provided and whether they can perform the tasks safely. This protects you legally and ensures continuity of care.

Time-Saving Tip

Create templates with your standard sections pre-formatted. Fill in patient-specific data during treatment sessions so you're not starting from scratch at discharge. Many clinicians add brief notes to a running discharge summary draft after each visit.

7. Keep It Concise but Complete

A discharge summary should be comprehensive but not verbose. Include all clinically relevant information, but avoid repeating the same data in multiple sections. Use bullet points and tables for easy scanning.

Avoid Common Pitfalls

Don't copy and paste progress notes into the discharge summary. The discharge summary should synthesize the entire episode of care, not repeat individual session details. Focus on the overall trajectory and outcomes.

Common Mistakes to Avoid

Even experienced OTs make documentation errors that can affect reimbursement, legal protection, and continuity of care. Here are the most common mistakes to watch for:

1. Inconsistent Terminology

Using "moderate assist" in the evaluation and "50% assistance" at discharge makes it harder to identify improvement. Stick to one system (FIM levels, percentage assistance, or descriptive levels) throughout.

2. Missing Baseline Comparisons

Stating the patient is "modified independent with dressing" at discharge means nothing without knowing where they started. Always include initial status alongside discharge status.

3. Vague Goal Outcomes

Writing "goal partially met - patient improved" doesn't tell the reader anything useful. Specify exactly how much improvement occurred: "Goal partially met - patient improved from Max A to Min A (expected outcome: Modified Independence)."

4. Forgetting Equipment

If the patient is using adaptive equipment to achieve their functional levels, this must be documented. "Independent with dressing" is very different from "Modified independent with dressing using reacher and sock aid."

5. Incomplete Caregiver Documentation

If a patient requires caregiver assistance at home, document who was trained, what they were trained on, and their demonstrated competency. This information is crucial for safety and continuity.

6. No Explanation for Early Discharge

If a patient is discharged before meeting goals, explain why. Whether it's patient choice, insurance denial, medical complications, or plateau - the reason needs to be documented for legal protection and future reference.

Initial functional status documented with objective measures
Discharge functional status documented with same measures
Clear comparison showing change (improved, declined, unchanged)
All goals listed with status and outcome data
Unmet goals have explanations
Equipment and assistive devices documented
HEP provided and patient/caregiver understanding confirmed
Caregiver training documented if applicable
Follow-up recommendations included
Therapist signature and credentials present

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Initial and discharge functional status pre-populated
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Consistent terminology throughout

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Frequently Asked Questions

What should be included in an OT discharge summary?

An OT discharge summary should include: patient demographics and diagnosis, reason for referral, initial functional status (ADL levels, ROM, strength, standardized assessments), treatment summary, discharge functional status with comparison to initial, goals with outcomes (met, partially met, not met), reason for discharge, home exercise program, equipment recommendations, caregiver training provided, and follow-up recommendations.

When should an OT write a discharge summary?

Write a discharge summary when the patient has achieved their functional goals, reached maximum benefit from skilled OT services, is being transferred to another level of care or facility, no longer requires skilled occupational therapy intervention, or when services are discontinued for any reason (patient request, non-compliance, insurance limitations, etc.).

How do you document functional outcomes in OT discharge?

Document functional outcomes by comparing initial and discharge status using objective measures. Include FIM scores or ADL independence levels, ROM and strength measurements, standardized assessment scores, and specific functional improvements. For example: "Dressing upper body: Minimal Assistance (Initial: Maximum Assistance) - improved 2 levels."

What is the difference between an OT discharge summary and a progress note?

A discharge summary provides a comprehensive overview of the entire episode of care from evaluation to discharge, including all goals and their outcomes. A progress note documents a single treatment session or short period. Discharge summaries are typically more detailed, include treatment summaries, and provide recommendations for continued care after OT services end.

Can a COTA write an OT discharge summary?

Requirements vary by state. In most states, COTAs can contribute to discharge documentation under OT supervision, but the supervising OT must review, approve, and co-sign the discharge summary. Some states require the OT to write the discharge summary directly. Always check your specific state practice act and facility policies for requirements.

How long should an OT discharge summary be?

Length depends on the complexity of the case and episode of care duration. A straightforward case might be 1-2 pages, while a complex case with multiple goals and comorbidities might be 3-4 pages. Focus on completeness and clarity rather than length. Include all required elements without unnecessary repetition.

What if the patient didn't meet their goals?

Document unmet goals honestly, but explain why they weren't achieved. Common reasons include medical complications, patient plateau, limited visits due to insurance, patient non-compliance, or change in patient priorities. Also document any partial progress made toward the goal and recommendations for future intervention if appropriate.

Do I need to include a home exercise program in the discharge summary?

Yes. The discharge summary should document that an HEP was provided, describe its key components, and confirm that the patient (and caregiver if applicable) demonstrated understanding and ability to perform the exercises. The actual HEP may be a separate attachment, but reference it in the summary.

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