Creating Therapy Discharge Summaries: A Time Saving Shortcut for Therapists!
A contract therapy client in Ohio asked the following question …
"What documents do you suggest be completed upon discharge? We love the Goals Summary
but you have to do a Progress Report to get the up-to-date status upon discharge. We also
have to complete the Discharge Summary. The Discharge Summary cannot stand alone as it
does not meet the LCD/NCD guidelines without a roll-up of progress towards goals. It's a lot of
work to make sure we are compliant. Can you recommend any shortcuts to reduce the amount
of time needed to create these documents?"
Our response is as follows …
Mary Gennerman, OTR/L, our Director of Clinical Services, researched CMS’s requirements for
discharge documentation. She did confirm that our documentation is fully compliant with NCD
as defined. Based on her analysis and your desire to find an easier way to document
discharges, we recommend a shortcut for discharge documentation as follows …
Create a “Final” Progress Report which can be used in lieu of our Discharge Summary.
Discontinue the use of our free standing Discharge Summary. Other clients use this approach
which is supported in the literature below. Specifically, “Where the physician writes a Discharge
Summary that meets the requirements of the provider setting, a separate discharge note written
by a therapist is not required. The discharge note shall be a Progress Report written by a
clinician, and shall cover the reporting period from the last Progress Report to the date of
discharge.”
The Progress field of the Current Report Status section of the Progress Report can be used to
document the "final" status of each goal right up to the discharge date. The Education,
Assessment, Plan/Justification, and Anticipated Discharge sections can be used to summarize
outcomes, the discharge plan, instructions for continuing care at home, and any other
information necessary for discharge. You will no longer display final statements in the
Functional Assessment or Measurable Data sections that appear on the Discharge Summary.
The flexibility of our Progress Report allows you to adapt selected document fields thus
eliminating the need for a free standing Discharge Summary. Library entries specific to
discharge issues can be added for these document fields so a "Final" Progress Report can be
customized quickly for discharge documentation.
CarePoint therapy management software takes a “total compliance” approach with respect to
documentation required by CMS. Other products may not provide the flexibility that CMS
allows. Our system design, data testing, and client input created a documentation system that
allows “patient centered” care and does not force “canned” documentation. Our clients can
review and manage all aspects of patient care. Our system will notify them if anything is a
concern or out of compliance.