physio-discharge-summary

Physiotherapy Discharge Summary

Discharge is where the gains are kept or lost. The patient leaves with a plan they will follow for a fortnight and then abandon, or with a clear idea of what to maintain, what a flare-up means, and what would justify coming back. This writes that — and handles the discharge nobody enjoys documenting, where the goals were not met and saying so plainly is the honest thing to do.

What This Skill Produces

• Outcomes against baseline — the initial goals and markers, with where they finished
• The self-management plan — what to keep doing, at what frequency, and for how long
• Flare-up guidance — what a flare means, what to do, and what it does not mean
• Return criteria — the specific circumstances that warrant coming back
• The referrer letter — what the referring clinician needs, in the length they will read
• Incomplete goals, recorded honestly — what was not achieved, why, and what was recommended

Required Inputs

Ask for these if not provided:

• The initial assessment — the goals set and the baseline markers
• The final measures — the same markers, at discharge
• The episode — number of visits, what was done, and how the patient responded
• The reason for discharge — goals met, plateau, patient choice, non-attendance, or onward referral
• What the patient is leaving with — the maintenance programme and any equipment or advice

Framework: Outcomes Against Goals, Then What Keeps Them

1. Report against the goals that were actually set. In the patient's original words. A discharge summary measured against goals invented at discharge is not a summary.
2. Show baseline to discharge. Both numbers. A final value alone hides whether anything happened.
3. Make maintenance minimal and specific. Two exercises twice a week, done for a year, beat six done for three weeks. Say how long to continue.
4. Explain flare-ups before one happens. Patients interpret a flare as failure and either return unnecessarily or give up. Tell them what it means and what to do.
5. Give explicit return criteria. Not 'come back if it gets worse' but the specific circumstances that would warrant review.
6. Write the referrer letter short. Outcome, what was done, what the patient is continuing with, and anything the referrer must act on. They will read the first four lines.
7. Record incomplete goals honestly. Plateau, non-attendance, or patient choice — state it factually, along with what was recommended. This is the entry that matters if the patient re-presents.

Output Format

Discharge summary: [patient] · [episode dates] · [visits] · [clinician]

Reason for discharge: [goals met / plateau / patient choice / non-attendance / onward referral]

Outcomes against goals

| Goal (as set) | Baseline | At discharge | Met |

|---|---|---|---|

Objective markers: [marker — baseline → discharge], one line each

Episode summary: [visits, over what period] · Treatment provided: [brief] · Response: [brief]

Self-management plan

| What | How often | For how long |

|---|---|---|

Why it matters: [one sentence the patient will remember]

If it flares up: [what a flare-up is and is not] · Do this: [specific steps] · This does not mean: [the reassurance that prevents an unnecessary return or an abandonment]

Come back if: [specific circumstances warranting review]

Incomplete goals: [what was not achieved · why · what was recommended]

---

To the referrer — [name, date]

> [Patient] was seen for [n] visits between [dates] for [problem]. Outcome: [one line against the referral question]. Treatment: [one line]. Continuing with: [maintenance]. For your attention: [anything requiring action, or 'nothing further required'].

> A documentation framework for a licensed clinician. It does not determine discharge readiness, interpret outcomes, or make recommendations for any individual patient. Clinical decisions and record-keeping standards remain the treating clinician's and their regulator's.

Quality Checks

• [ ] Outcomes are reported against the goals originally set, in the patient's words
• [ ] Both baseline and discharge values are shown
• [ ] The maintenance plan is minimal, specific, and has a stated duration
• [ ] Flare-up guidance explains what a flare does and does not mean
• [ ] Return criteria are specific circumstances, not 'if it gets worse'
• [ ] The referrer letter leads with the outcome in one line
• [ ] Unmet goals are recorded factually with what was recommended

Anti-Patterns

• Goals invented at discharge. Makes the summary meaningless and flatters the episode.
• Discharge values with no baseline. The reader cannot tell whether anything changed.
• A maintenance programme as long as the treatment programme. Nobody sustains it.
• No flare-up guidance. The first flare is read as relapse and undoes the education.
• 'Come back if it gets worse.' Too vague to act on in either direction.
• A referrer letter nobody finishes. Put the outcome in line one.
• Hiding an unmet goal. The record that matters most if the patient re-presents.

Example Trigger Phrases

• "Write a discharge summary for a patient finishing rehab"
• "Discharge a patient who has plateaued"
• "Write a letter to the GP at discharge"
• "What should the patient leave with at discharge?"
• "How do I document discharging someone who stopped attending?"