A physiotherapy discharge summary format that records the outcome of every goal, with a sample entry for each section.
✓Start and discharge measures together
✓Clear return criteria for patients
✓Closes files for no-shows too
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What's inside
Reason for Discharge
Presenting Problem and Episode of Care
Outcomes Against Goals
Measures at Start and Discharge
Current Function and Remaining Needs
Home Exercise and Self-management
When to Return or Seek Help
Onward Referrals and Communication
+ 1 more sections
Preview · 9 sections
Physiotherapy Discharge Summary
Patient
Patient ID
Date of birth
Discharge date
Referred by
Physiotherapist
Episode of care (dates)
Sessions attended / planned
Reason for Discharge
☐ Goals achieved
☐ Patient chose to stop or self-manage
☐ Progress plateaued, agreed with the patient
☐ Referred on to another service
☐ Did not return
☐ Other (describe below)
Reason for discharge
Presenting Problem and Episode of Care
Presenting problem at referralAs documented in the referral and initial assessment.
Treatment provided
Outcomes Against Goals
Goal (as written in the plan)
At Start
At Discharge
Outcome
Measures at Start and Discharge
Measure
Method / Position
At Start
At Discharge
Pain (scale named)
Range of motion
Strength
Balance and gait
Functional mobility and transfers
Outcome measure used by the clinic (name)
Current Function and Remaining Needs
Current function
Remaining needs
Home Exercise and Self-management
Maintenance programme
Activity and return-to-work advice given
When to Return or Seek Help
Return and re-referral criteria
Onward Referrals and Communication
Onward referrals
Copies sent to
Therapist Sign-off
Therapist
Designation
Registration
Date
How to fill it in
1
Reason for Discharge
Tick the reason and explain it factually in a line or two.
More guidance
Tick the reason and explain it in a line or two. Be factual and neutral, especially when the patient stopped attending or chose to end early. If the plan was to continue until the goals were met but cost or travel ended treatment sooner, record that, because it explains the outcomes that follow.
2
Presenting Problem and Episode of Care
Referral reason, episode dates, sessions attended, and the main types of treatment.
More guidance
Give the reason for referral as documented, the dates of the episode, the number of sessions, and the main types of treatment provided. A reader should grasp the shape of the episode in under a minute. Session-by-session detail stays in the notes.
3
Outcomes Against Goals
Each goal word for word, where the patient started and finished, and the outcome.
More guidance
List each goal from the treatment plan word for word, with where the patient started, where they are at discharge, and the outcome: achieved, partly achieved or not achieved. Do not soften unmet goals; give the reason in a few words if you know it. Readers trust a summary that reports misses as plainly as successes.
4
Measures at Start and Discharge
Key baseline measures repeated the same way, side by side with the start values.
More guidance
Repeat the key baseline measures under the same conditions and set them side by side. Include pain on the same named scale and, if your clinic uses an outcome measure, its name and both results as its manual reports them. If a measure was not repeated, say why.
5
Current Function and Remaining Needs
What the patient can do now in everyday terms, and what is still limited.
More guidance
Describe what the patient can do now in everyday terms, and what is still limited. Remaining needs are not a failure of treatment. Recording them honestly tells the patient what to expect and tells a future clinician where to start.
6
Home Exercise and Self-management
Maintenance exercises, how long to continue them, and the advice you actually gave.
More guidance
Name the maintenance exercises, how often and for how long to continue them, plus any activity or return-to-work advice you actually gave. Attach or refer to the final HEP sheet. Write it so the patient could follow it six months from now without calling you.
7
When to Return or Seek Help
Clear criteria for coming back or seeing a doctor, and how to re-book.
More guidance
Give the patient clear criteria for coming back or seeing a doctor, such as symptoms returning enough to limit a named activity, a new injury, or a set period without improvement. Include how to re-book and whether a new referral is needed under your clinic's policy.
8
Onward Referrals and Communication
Referrals made, to whom and why, and everyone who receives a copy.
More guidance
Record any referral you made, to whom, why and how it was sent, and list everyone who received a copy of this summary. Check the patient's consent before sending it beyond the referring doctor.
Physiotherapy 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
Discharged after 12 sessions. Main goals achieved; patient confident to continue the home programme on her own.
Presenting Problem and Episode of Care
Referred by Dr N. (orthopaedics) 5 weeks after left knee replacement. Seen from 14 August to 30 October; attended 12 of 14 planned sessions. Treatment: progressive strengthening, knee range work, walking and stair practice, home programme.
Outcomes Against Goals
Goal: climb 14 steps step over step without resting. Start: one step at a time with rail, one rest. Discharge: step over step with one rail, no rest. Outcome: achieved.
Measures at Start and Discharge
Left knee flexion, active, supine, goniometer: start 95°, discharge 120°. Pain at worst on the 0–10 scale: start 7, discharge 2.
Current Function and Remaining Needs
Walks outdoors for 30 minutes without an aid. Sits on the floor for meals and rises with one hand on a low stool. Still avoids kneeling on the left knee.
Home Exercise and Self-management
Continue sit to stand, step-ups and calf raises on 4 days a week (final HEP sheet dated 30 October). Morning walks resumed; increase from 30 to 45 minutes over the next month as comfort allows.
When to Return or Seek Help
Contact the clinic if knee pain stops you walking for 15 minutes on most days of a week, or if swelling returns. No new referral is needed within 6 months.
Onward Referrals and Communication
Copy to Dr N. by email and to the patient in print. At her request, details given for the community walking group run by the hospital.
Discharge summary or final progress report?
Final progress report
Discharge summary
Purpose
Reviews a period and plans the next one
Closes the episode and hands over to the patient or the next service
Goals
Status of current goals, plus new goals
Final outcome for every goal, with no new goals
Plan
The next block of treatment
Maintenance, return criteria and onward referral
Main reader
Treating team and referrer
Patient, referrer and any future physiotherapist
When
At a review point
At the last session, or when an episode is closed
Tips and mistakes to avoid
Do
Write the summary while the final session is fresh; summaries written weeks later lose the numbers.
Give the patient a plain-language copy, even if a relative keeps the paperwork, and check which exercises continue.
Close the episode for patients who stopped attending, with two lines on their last known status.
For ward discharges, add destination, mobility and transfer status, equipment provided, and any community physiotherapy arranged.
Clinics using healhab can save this as their own discharge template in Template Studio and keep versions.
Avoid
'Goals achieved, discharged' with no measures behind it.
Reporting only the goals that were met.
No maintenance programme, so gains fade once sessions stop.
Return advice so vague, such as 'come back if needed', that the patient cannot act on it.
Leaving files open for months after a patient stops attending.
About this discharge summary
A physiotherapy discharge summary closes an episode of care: why physiotherapy is ending, what was achieved against each goal, measures at the start and at discharge, the maintenance programme, when to return, and any onward referral. This free template has tables for outcomes and measures, and edits online or downloads as a PDF.
When goals are met and self-management begins
When the patient stops or progress levels off
When referring on to another service or setting
When the patient has not returned
Read more
The discharge summary closes a physiotherapy episode and is often the only page a future clinician reads. It shows what was tried, what worked, and where the patient finished, for the patient, referrer and next physiotherapist.
Write it at the final session, or soon after a patient stops coming. Indian hospitals often ask for a 'discharge format'; US clinics say physical therapy discharge summary.
Questions
What should a physiotherapy discharge summary include?+
The reason for discharge, the episode of care, outcomes against every goal, measures at start and discharge, current function and remaining needs, the maintenance programme, return criteria, and onward referrals and copies. The template has a heading or table for each.
Is there a filled sample of this discharge summary?+
Yes. Each section in the guide above shows a fictional sample entry for one patient, initials only. The samples show wording and layout; the outcomes and judgements about the episode are the treating physiotherapist's to write.
When should a patient be discharged from physiotherapy?+
When the agreed goals are met, when progress has levelled off and you both agree more sessions are unlikely to help, when the patient chooses to stop, or when they need a different service. The treating physiotherapist decides with the patient.
How do I write a discharge summary for a patient who stopped coming?+
Record the last session date, the measures from that session, each goal's status at that point, and any attempts to contact the patient. Tick 'Did not return' and keep it short and neutral.
Is there a physiotherapy discharge format for hospital wards?+
This template works on wards as well as in outpatient clinics. Add the discharge destination, mobility and transfer status, equipment provided, and any community physiotherapy arranged.
Should a discharge summary include a home exercise programme?+
Yes. Name the exercises and how often, and attach the final HEP sheet, so the patient and any future clinician know exactly what to continue.
Who should receive a copy?+
The patient and the referring doctor at a minimum, with the patient's consent, plus a copy in the clinic's records. Download the summary as a PDF to print or send.
