What is included in a Physical Therapy discharge summary?!


Question: I am a PTA student and we are doing an exercise program project and we are now at the part of writing the discharge summary. Our teacher never told us what exactly is in one, and since we aren't PT students it hasn't been taught otherwise. Thanks!


Answers: I am a PTA student and we are doing an exercise program project and we are now at the part of writing the discharge summary. Our teacher never told us what exactly is in one, and since we aren't PT students it hasn't been taught otherwise. Thanks!

A PTA shouldn't be writing a discharge summary since it includes assessment.

Yet, PT discharges are generally not as extensive as listed above. Rather, it should include:

Their medical and/or PT diagnosis.

Objective measurements as related to goals or current level of function (such as AROM in someone who has had a TKA).

The patient's current functional status.

How many visits the patient attended and how many were missed.

List goals and whether or not they were attained.

If goals were not attained, it should include any barriers to treatment/learning/compliance, etc.

Finally, it should include any final recommendations as made by the PT (such as: return to physician, continue home exercise program, etc).

Attending Physician:

Date of Admission:
Date of Discharge:

Admitting Diagnosis:
Discharge Diagnosis:

History of Presenting Illness
Past Medical History
Past Surgical History
Review of Systems
Physical Exam:
Medications
Allergies
Labs:
Hospital Course:
Assessment/Plan:





The consumer health information on answer-health.com is for informational purposes only and is not a substitute for medical advice or treatment for any medical conditions.
The answer content post by the user, if contains the copyright content please contact us, we will immediately remove it.
Copyright © 2007-2011 answer-health.com -   Terms of Use -   Contact us

Health Categories