Considerations for Required Elements of a Discharge Summary

By: Jennifer Heiligman, PT, MPT

A Discharge Summary, or the Conclusion of the Episode of Care Summary, is a required element of documentation that can often be overlooked.  Medicare requires a Discharge Summary be completed for each outpatient therapy episode of care.  The purpose of the discharge summary is to summarize the patient’s progress toward their established goals, provide their current functional status and to indicate how the patient plans on managing their condition post discharge.

We will reference Medicare’s requirements for a discharge summary since they generally have the most stringent requirements and most other payers follow their lead.  Per Medicare, a discharge summary should include essentially the same information required for a progress note, plus some additional information relevant to the decision to end the episode of care.

A discharge report written by a therapist shall include:

  • Documentation of the patient’s subjective statements, if relevant
  • Updated objective measures, including validated outcome surveys
  • Extent of progress toward each goal; which goals have been attained and which were not achieved
  • Information or education that was provided to the patient or caregiver including a Home Exercise Program (HEP) or other training
  • The reason for discharge including the clinician’s clinical justification supporting the reasoning

The discharge summary is essentially the last opportunity the therapist has to justify the medical necessity of the treatments that were rendered during this episode of care.  Therefore, additional relevant information may also be included in the report at the discretion of the therapist.  An example may be additional documentation justifying the necessity to extend an episode of care longer than would normally be expected based on the impairment or diagnosis.  This justification may be important should the chart ever be selected for an audit. 

How do you complete a discharge summary when a patient performs an unanticipated self discharge, or in layman’s terms, just stops showing up to therapy?  Unfortunately, this can be a reality in our profession.  In this scenario, the therapist would generate an Absent Discharge Summary.  The therapist should attempt to make contact with the patient in order to obtain final subjective information and maybe even the reason for not returning to therapy.  If obtained, this information can be included within the absent discharge summary.  If contact is not able to be made, that can be documented as well within the report to illustrate the effort that was made to obtain information.  Per Medicare, when an absent discharge is necessary, the clinician may base any judgements required to write a discharge summary on the previous treatment and progress notes from that patient’s episode of care.   A rationale for discontinuation of therapy should also be included in the absent discharge summary.

As indicated above, a discharge summary is a very important part of the required documentation during a patient’s episode of care.  This is essentially your last chance to support the medical necessity of the skilled services you provided. Should a Medicare contractor come calling, you want to make sure all required elements are represented. For additional information regarding Medicare Requirements for Documentation of Therapy Services, please reference CMS’ Medicare Benefit Policy Manual; Chapter 15; Section 220.3.