Occupational therapy discharge summary format and sample
An occupational therapy discharge summary format covering goal outcomes, current function and handover, with a sample entry for each section.
✓Final outcome for every goal
✓Equipment list families can follow
✓Clear signs for when to return
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What's inside
Reason for Discharge
Episode of Care
Outcomes Against Goals
Function in Daily Occupations at Discharge
Equipment, Adaptations, and Handover
Clinical Summary at Discharge
Recommendations After Discharge
When to Return
+ 1 more sections
Preview · 9 sections
Occupational Therapy Discharge Summary
Client
Client ID
Date of birth
Discharge date
Therapist
Episode of care
Sessions attended
Referred by
Reason for Discharge
Reason for discharge
Episode of Care
Referral concern and occupational priorities at the start
Therapy providedDates, frequency, settings, approaches, and who was involved.
Outcomes Against Goals
Goal
At Start
At Discharge
Outcome
Evidence
Function in Daily Occupations at Discharge
Occupation
Current Independence / Support Needed
Equipment / Adaptations in Place
Self-care
School or work
Play or leisure
Home and community
Equipment, Adaptations, and Handover
Equipment and adaptations to keep using
Information shared, with whom, and consent recorded
Clinical Summary at Discharge
Clinical summary
Recommendations After Discharge
Home, school, or work recommendations
Onward referrals
When to Return
Re-referral criteriaChanges in daily activities that should prompt the family to contact the clinic.
Therapist Sign-off
Therapist
Designation
Registration
Date
How to fill it in
1
Reason for Discharge
Why therapy is ending, in one or two factual sentences.
More guidance
Give the reason in one or two factual sentences: goals achieved, family decision, relocation, transfer, non-attendance or a change in medical status. If the discharge was not planned, say so neutrally.
2
Episode of Care
The referral concern, then dates, frequency, settings and approaches used.
More guidance
Summarise the referral concern and the starting priorities, then the therapy provided: dates, frequency, settings such as clinic, home or school, the approaches used and who was involved. A short paragraph for each is enough.
3
Outcomes Against Goals
Every goal with its start, discharge performance on the same measure, and outcome.
More guidance
List every goal from the latest plan with its starting point, performance at discharge on the same measure, and the outcome. Use the clinic's outcome terms consistently and name the evidence source. Include discontinued goals and say why they stopped.
4
Function in Daily Occupations at Discharge
How the person manages daily occupations now, with support and equipment in place.
More guidance
Describe how the person manages self-care, school or work, play or leisure, and home and community life now, with the support still needed and the equipment in place. The next school or therapist often reads this table first.
5
Equipment, Adaptations, and Handover
Equipment to keep using, and what was shared, with whom, with consent.
More guidance
List equipment and adaptations to keep using, where they came from and who looks after them. Record what information was shared, with whom, and how consent was given: the school, the next therapist, the referring doctor.
6
Clinical Summary at Discharge
Your short statement of where the person stands now and what needs remain.
More guidance
The treating occupational therapist writes and confirms this section. Draw the outcome and function tables together into a short statement of where the person stands at discharge and what remains. Do not add new findings. State remaining needs plainly so the next professional can plan, and keep the wording readable for the family.
7
Recommendations After Discharge
A few practical steps the family can carry out without a therapist.
More guidance
Give a small number of practical recommendations for home and school or work, and any onward referrals with the reason. Each recommendation should be something the family can carry out without a therapist present.
8
When to Return
Signs in daily life that should prompt the family to contact OT again.
More guidance
List the specific signs that should prompt the family to seek OT again, and how to contact the clinic. Phrase them as changes in daily activities that a family can notice for themselves.
Occupational therapy discharge summary format and sample: filled sample
Fictional entries, initials only, showing the level of detail to aim for. Impression and summary sections are left for the treating clinician.
Reason for Discharge
Family relocating to Pune in June. Discharged with the family's agreement after the final review on 30 May.
Episode of Care
Referred by paediatrician in July for difficulty with dressing and handwriting. Weekly 45-minute clinic sessions from July to May, plus two school visits. Parents and grandmother attended in turn.
Outcomes Against Goals
Goal: copy two lines into the four-line notebook with letters on the base line. Start: 4 of 10 letters. Discharge: 9 of 10 on 3 consecutive homework days (session notes, teacher samples). Outcome: achieved.
Function in Daily Occupations at Discharge
Self-care: dresses for school alone when clothes are laid out; needs help with the tie. School: copies from the board using a slant board; teacher reports long passages are sometimes unfinished.
Equipment, Adaptations, and Handover
Continue: pencil grip, slant board (family-owned), picture checklist for the morning. Shared: a copy of this summary with the new school's special educator, with parents' written consent.
Recommendations After Discharge
Keep the picture checklist on the bedroom door. Ask the new class teacher to allow the slant board. See a local OT if handwriting demands increase in the next class.
When to Return
Contact us if R. needs help to dress again for more than two weeks, or if the teacher reports written work is often unfinished.
OT discharge summary vs OT progress report
Discharge summary
Progress report
Written when
Therapy ends or transfers
At review dates during therapy
Covers
The whole episode of care
One reporting period
Goal status
Final outcome for each goal
Current status and goals for the next period
Looks ahead to
Life without regular OT, and when to come back
The next period of therapy
Main readers
Family, next provider, school, referrer
Family, school, referrer
Tips and mistakes to avoid
Do
Write it within a few days of the last session and give the family a copy.
For families moving city, write for a professional who has never met the child.
Name equipment by its everyday name too, so a grandparent can find it.
Record the family's languages so the next therapist can plan the first sessions.
In healhab, a published discharge summary stays in document history, and corrections create a new version.
Avoid
Leaving out goals that were not achieved.
Using a different measure at discharge from the one in the plan.
Recommendations that need a therapist to carry them out.
No guidance on when to come back.
About this discharge summary
An occupational therapy discharge summary closes an episode of care. It records why therapy is ending, what was provided, the outcome for each goal, how the person manages daily occupations now, the equipment and adaptations to continue, recommendations and when to return. This free template, which also serves as an OT discharge note, follows that order.
The treatment plan goals are met
Family moving city, changing centre or pausing long-term
An adult leaving rehabilitation for home or work
Transfer to school-based or another OT service
Read more
Discharge can mean the goals were met, the family stopped, the child moved, or another service took over. In every case the summary gives a clear, factual account of the whole episode.
The treating OT writes it from the plan, progress reports and notes. Indian families often carry it to the next school or doctor, so plain language and a clear equipment list matter.
Questions
What should an OT discharge summary include?+
The reason for discharge, referral concern and therapy provided, the outcome for each goal, current function, equipment and handover, the therapist's clinical summary, recommendations, re-referral criteria and sign-off.
What is the difference between a discharge summary and a discharge note?+
The terms are often used interchangeably. In hospitals a discharge note may be a brief record entry, while the summary is the fuller document for the family and next provider. This template is the fuller version.
What is the usual discharge summary format in India?+
Indian clinics usually follow this order: details, reason for discharge, therapy provided, outcomes, current function, recommendations, and a signature with registration details where the clinic requires them.
Should I write a discharge summary if the family stops attending?+
Yes. Record the last session date, your attempts to contact the family and each goal's status at that point. It keeps the record complete if the family returns.
How do I describe goals that were not achieved?+
State the goal, the start and discharge performance on the same measure, then mark it partly achieved, not achieved or discontinued. Add a short factual reason and carry remaining needs into the recommendations.
Is there a filled sample of this discharge summary?+
Yes. Each section guide shows a fictional sample entry, initials only. The clinical summary at discharge has no sample; the treating therapist writes it from the outcome and function tables.
Can the family share the discharge summary with a new school?+
Yes, it is their document. Write it so a teacher or special educator can follow it without OT training, and download it as a PDF from the free editor.
