Templates by document

Therapy discharge summary format and sample

A therapy discharge summary format with sample entries, for both planned and unplanned endings of therapy.

Choose your therapy

Formats for

Discharge summaries by therapy

Speech therapySpeech therapy discharge summary template and exampleA speech therapy discharge summary format with an outcomes-by-goal table, clear return criteria, and example entries throughout.
Occupational therapyOccupational therapy discharge summary format and sampleAn occupational therapy discharge summary format covering goal outcomes, current function and handover, with a sample entry for each section.
ABA & behaviour therapyABA and behaviour therapy discharge summary format and sampleAn ABA discharge summary format with sample entries for outcomes by goal, a maintenance plan, handover and return signs.
Early intervention & child developmentEarly intervention discharge and transition summary formatAn early intervention discharge summary format written for the next teacher or therapist, with sample entries for each section.
PhysiotherapyPhysiotherapy discharge summary format and sampleA physiotherapy discharge summary format that records the outcome of every goal, with a sample entry for each section.
Multidisciplinary rehabilitationRehabilitation discharge summary format and exampleA rehabilitation discharge summary format with example entries, written for the family and whoever provides care next.

The essentials

What goes in a therapy discharge summary?

Dates, referral reason, services, goals at discharge, reason for discharge, recommendations and copies.

Identifying details and dates: first and last session and the treating therapist.
Reason for referral, in a sentence or two.
Services provided: therapy type, frequency, approximate number of sessions, and any home or school programme.
Goals at discharge: each goal with its baseline, final measure and status.
Reason for discharge: goals achieved, family decision, move to another service, ongoing absence, or another reason.
Recommendations: what to continue, supports for school or work, referrals, and signs that suggest coming back.

These sections cover what the next reader will need.

Planned and unplanned discharge

Planned: describe final progress fully. Unplanned: record what you know, neutrally, and leave the door open.

A planned discharge follows goals being met or an agreement that therapy has done what it can for now. Describe final progress in full and hand over a maintenance programme.

An unplanned discharge follows a family stopping, moving or switching services without notice. Record the last session, progress to that point and contact attempts, in a neutral tone. Families stop for board exams, fees, travel or a family event, so leave the door open.

How do discharge summaries differ by therapy?

Each therapy describes status at discharge in its own terms and says what should continue.

Speech and OT summaries describe skills at discharge and their use at home and school. ABA summaries list mastered targets and how to keep strategies consistent. Early intervention summaries often mark a move to preschool or school. Physiotherapy compares first and last measures and hands over a home programme. Rehabilitation teams combine each discipline into one summary.

Discharge summary or final progress report?

A final progress report covers the last period. A discharge summary covers the whole episode.

A discharge summary runs from referral to the last session and adds the reason for discharge and the plan for afterwards. If your last progress report was recent, refer to it and focus on what changed since and what comes next.

Writing recommendations people can act on

Name the action and the person who will carry it out.

"Class teacher to seat K. near the front and give instructions one step at a time" helps a school more than "classroom support recommended". For families, list two or three things to keep doing at home and the changes that would be a reason to come back.

About discharge summaries

A therapy discharge summary closes an episode of care. It records the dates and frequency of therapy, the reason for referral, each goal's status at discharge, the reason therapy is ending, and recommendations for home, school or other services, including when to seek therapy again. The templates below give speech, OT, ABA, early intervention, physio and rehab versions.

Discharge is easy to rush. The family stops coming, or goals are met and everyone moves on. Yet the next therapist, school or doctor will ask for this summary, sometimes years later.

The format below works for both a planned and an unplanned end to therapy.

Questions

Is there a filled sample of a discharge summary?

Each therapy template page shows a fictional sample entry for each section, using initials only. Any overall summary or impression has guidance only, because that wording belongs to the treating clinician.

When should a discharge summary be written?

As soon as possible after the last session, while data and details are fresh. Many clinics set a deadline of one or two weeks.

Who receives the discharge summary?

The family, and with their agreement the referring doctor, school or next service. Keep a copy in the clinical record.

What if the family stopped coming without notice?

Write an unplanned discharge summary with the last attended date, progress to that point and the contact attempts made, and recommend how to resume if they wish.

Can I download a discharge summary format as a PDF?

Yes. Fill in the template online and download it, or download it blank to complete by hand.

Should a discharge summary repeat the whole assessment?

No. Summarise the reason for referral in a line or two and spend the document on progress, status at discharge and recommendations.

Write every report inside your clinic system.

Keep these as your clinic's own templates, write from reviewed session notes, publish branded PDFs, and keep families updated.

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