A physical therapy discharge summary closes the episode of care: why it ended, what changed, and what the patient does next. Copy the free template, see two filled examples, and check what the patient and the referrer need from it.
Blank physical therapy discharge summary template
FreePHYSICAL THERAPY DISCHARGE SUMMARY Patient: [Name] Date of birth: [Date] Date of discharge: [Date] Episode of care: [Date of evaluation to date of last visit] Visits: [Visits attended, canceled, and missed] Treatment diagnosis: [Condition and body region] Referring clinician: [Name, if any] Therapist: [Name, credentials] REASON FOR DISCHARGE Reason: [Goals met, plateau, patient choice, non-attendance, medical change, or transfer of care] Details: [What led to the decision, and whether it was planned with the patient] COURSE OF CARE Summary: [Main interventions and the patient's response over the episode] Events: [Flare-ups, falls, medical changes, or none] OUTCOMES Pain: Initial [score out of 10] | Final [score out of 10] Range of motion: Initial [joint, motion, degrees] | Final [degrees] Strength: Initial [muscle group, grade] | Final [grade] Function: Initial [gait, balance, or task result] | Final [result] Outcome measure: Initial [name, score] | Final [score] Final measures taken: [Date of the last measures, if not at discharge] GOALS Goals met: [Each goal achieved, with the final value] Goals not met: [Each goal not achieved, the final value, and why] STATUS AT DISCHARGE Current function: [Mobility, self-care, work, sport, device or assist level] Home exercise program: [Exercises, dosage, and how long to continue; written copy given] Independence with the program: [How the patient showed they can do it alone] RECOMMENDATIONS Ongoing care: [Self-management, community exercise, equipment, activity advice] Follow-up: [Appointments with the referring clinician or surgeon] When to seek care: [Symptoms that should prompt a call, a review, or urgent care] Returning to therapy: [How to come back, and when that would make sense] Copy sent to: [Referring clinician or others] Signed: [Clinician name, credentials, date and time]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Outpatient clinic, discharge after 12 visits
Goals met. Discharge was planned with the patient at the last progress report.
64-year-old man, seen from 4 to 14 weeks after a right total hip replacement. 12 visits over 10 weeks, none missed. Progressive hip and leg strengthening, gait training to wean off the cane, balance and stair training, and golf-specific practice. A week of lateral hip soreness after a jump in walking distance settled with a lighter load. No other events.
Pain with walking: initial 4/10, final 0/10. Hip flexion AROM: initial 85°, final 105°. Hip abduction strength: initial 3/5, final 4+/5. Gait: initial cane with a right Trendelenburg pattern; final no device, even pattern for 1 km (0.6 mi). 30-Second Chair Stand: initial 8, final 14. HOOS JR: initial 48, final 82.
All met: walk 1 km (0.6 mi) without a device or pain; stairs step-over-step with one rail; car transfers independently; HOOS JR 75 or higher; hit golf balls at the range for 30 minutes without pain.
Independent in all mobility and self-care without a device. Driving again with his surgeon’s clearance. Home program: side-lying hip abduction 3 × 12, bridges 3 × 12, step-ups 3 × 10, and single-leg balance 3 × 30 s, 3 times a week for at least 3 months, plus daily walking. Did every exercise correctly without cues at the final visit.
Build up to walking 9 holes of golf over 4 to 6 weeks. Surgeon follow-up as booked. Seek urgent care for sudden hip pain with inability to bear weight, or fever with redness or drainage at the wound. Contact the clinic to come back if a limp, weakness, or new pain develops. Copy sent to his surgeon and family physician.
Outpatient clinic, discharge after 7 of 12 planned visits
Progress plateaued and visits stopped. No change in measures from visit 4 to visit 7, despite changes to the program. Did not attend the last 3 booked visits. Reached on the second phone call: her work schedule makes visits hard, and she prefers to continue on her own. Discharge agreed by phone.
58-year-old woman with left knee osteoarthritis. 7 visits over 8 weeks: quadriceps and hip strengthening, a walking program, education on managing load, and a trial of manual therapy. Gains in pain and stair tolerance over the first 3 visits, then no further change.
Final measures from visit 7, 3 weeks before discharge. Pain on stairs: initial 6/10, final 4/10. Knee flexion AROM: initial 110°, final 118°. Quadriceps strength: initial 4-/5, final 4/5. 30-Second Chair Stand: initial 9, final 11. 6-minute walk test: initial 380 m (1,250 ft), final 420 m (1,380 ft). Lower Extremity Functional Scale: initial 38/80, final 45/80.
Met: walk 30 minutes on level ground with pain 3/10 or less. Not met: stairs step-over-step without a rail; stair pain 2/10 or less; 30-Second Chair Stand of 13 or more. Progress on these stopped after visit 3.
Walks in the community without a device; uses the rail on stairs. Home program reviewed at visit 7 and given in writing: sit to stand 3 × 10, step-ups 3 × 10, straight-leg raises 3 × 12, and a walking plan, 3 days a week, ongoing. Did the program correctly at that visit.
Continue the home program and walking plan. Options for pain relief and weight management, which she raised, to discuss with her family physician. See her physician for a hot, swollen knee, locking, giving way, or pain that stops her walking. Welcome to return with a new referral, or by self-referral where accepted, if her schedule or goals change. Copy sent to her family physician.
Why care ended, stated plainly, and whether the decision was planned with the patient.
Avoid: Labels such as “non-compliant.” Record the facts: visits missed and the contact you attempted.
A short summary of the episode: what you did and how the patient responded.
Avoid: Retelling every session. A few lines is enough.
Initial and final values for the measures that matter, side by side.
Avoid: Final values with no initial values beside them. The comparison is the point.
Each goal from the plan of care, marked met or not met, with the final value.
Avoid: Leaving out the goals that weren’t met. They matter to the next clinician.
Where the patient is now, and how they will keep going on their own.
Avoid: A home program with no dose or end point. Say how often, and for how long.
What should happen next, and when the patient should seek care or come back.
Avoid: Ending without warning signs or a route back to care.
State why care ended. “Goals met” and “stopped attending” lead the referrer to very different next steps.
Write the facts, such as visits missed and contact attempts, rather than labels like “non-compliant” or “unmotivated.”
If there was no final visit, report the last measures taken and say when they were taken.
Give the dosage and how long to continue, and record that the patient can do it correctly.
Tell the patient and the referrer what should prompt a return, and how to come back.
Dictate the outcomes and the plan, or record the final session with the patient’s consent. Vero Scribe writes the discharge summary in your template; you edit it, then export it to PDF or Word, print it, or email it to the referrer.
The reason for discharge, the dates and number of visits, a summary of care, initial and final measures, goal status, function at discharge, the home program, recommendations, and follow-up.
Record the last visit attended, the measures from that visit, the visits missed, and your attempts to reach the patient, in neutral language. State the reason for discharge and send a copy to the referrer.
Yes, when progress has stopped despite changes to the plan and more skilled care is unlikely to help. Record the measures that show it, what you tried, and the home program the patient will continue.
Usually the referring clinician, and others involved in care with the patient’s agreement. Give the patient the home program and the warning signs in writing.
Yes. Copy it, or download it as a Word or text file. No account needed.
Follow-up visit note with pain, ROM, MMT, special tests, timed interventions, and the home program.
Initial evaluation with history, systems review, tests and measures, prognosis, goals, and plan of care.
Per-visit treatment log: each intervention with parameters and minutes, the response, and next steps.
Re-assessment with measures beside baseline, goal status, updated goals, and the case to continue.
The hospital discharge summary, with a worked example and a quality checklist.
Clear, patient-friendly instructions, drafted with Vero and edited by you.
PT note examples, from evaluation to discharge.
Notes, documents, and follow-up in one workspace.
The codes used most often in physical therapy.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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