Rehabilitation discharge summary format and example
A rehabilitation discharge summary format with example entries, written for the family and whoever provides care next.
✓Outcomes against each shared goal
✓Carer training and equipment recorded
✓Clear advice on when to return
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What's inside
Reason for Discharge
Rehabilitation Episode
Outcomes Against Shared Goals
Function at Discharge
Equipment, Home Changes and Carer Training
Risks and Precautions at Discharge
Ongoing Needs and Onward Referrals
Recommendations After Discharge
+ 3 more sections
Preview · 11 sections
Rehabilitation Discharge Summary
Patient
Patient ID
Date of birth
Discharge date
Start of rehab episode
Key worker
Discharge destination
Setting (inpatient, day, outpatient)
Reason for Discharge
Reason for discharge
Rehabilitation Episode
Discipline
Lead Clinician
Sessions Attended
Main Focus
Physiotherapy
Occupational therapy
Speech and language therapy
Psychology / counselling
Rehabilitation nursing
Overview of the programmeSetting, intensity, family involvement, home visits and community outings.
Outcomes Against Shared Goals
Shared Goal
At Start
At Discharge
Outcome
Function at Discharge
Domain
What the Patient Does Now
Help Needed
Who Provides It
Mobility and transfers
Self-care and daily living
Communication and swallowing
Cognition
Psychosocial wellbeing
Community and vocational participation
Equipment, Home Changes and Carer Training
Equipment issued, loaned or still to arrive
Home changes made
Carer training completedName each carer, what they were trained in, and whether they demonstrated it safely.
Risks and Precautions at Discharge
Current risks and precautions
Ongoing Needs and Onward Referrals
Need
Referred To
Status
Contact
Recommendations After Discharge
Recommendations for the patient and family
When to Return or Seek Review
When to contact the centreChanges that should prompt a call, how to re-refer, and any review already booked.
Copies Sent To
☐ Patient
☐ Family member or main carer
☐ Referring doctor
☐ Family doctor
☐ Community or outpatient therapist
☐ Others the patient has agreed to, such as an employer
Therapist Sign-off
Therapist
Designation
Registration
Date
How to fill it in
1
Reason for Discharge
Say plainly why the episode ended, and whether it was earlier than planned.
More guidance
Say plainly why the episode ended: goals achieved, planned programme length completed, transfer to another service, readmission to hospital, the patient's or family's choice, or funding. If discharge came earlier than planned, record that without blame and note whether the team discussed it with the patient and family.
2
Rehabilitation Episode
List each discipline, lead, sessions and focus, then describe the programme in a paragraph.
More guidance
Fill the table with each discipline involved, its lead clinician, sessions attended and main focus. Then add a short paragraph on the programme as a whole: setting, intensity, family involvement, and any home visits or community outings. A new provider reads this to understand what has already been tried, so name approaches rather than listing every session.
3
Outcomes Against Shared Goals
For each shared goal, give start and discharge position in the same units, and the outcome.
More guidance
Copy each shared goal as it stood at the end of the episode, with the starting point and the position at discharge in the same units. Give the outcome and a short reason for any goal not achieved, such as illness, a changed priority, or early discharge. Report what was observed at discharge and leave predictions out.
4
Function at Discharge
One line per domain: what the patient does now, with what help, from whom.
More guidance
One line per domain: what the patient does now, with what help, and from whom. A community therapist will plan the first home visit from this table, so be concrete about equipment, setting and the person helping. If function differs between morning and evening, or between the centre and home, say so.
5
Equipment, Home Changes and Carer Training
List equipment and home changes, and what each carer was trained in.
More guidance
List equipment issued, loaned, bought by the family or still awaited, with who supplied it and who to contact about loans. Record home changes made, such as grab rails or a bed moved to the ground floor. For carer training, name each carer, what they were trained in, and whether they demonstrated it safely before discharge.
6
Risks and Precautions at Discharge
Copy current risks and precautions exactly as the responsible clinician confirmed them, with the date.
More guidance
Copy the current risks and precautions exactly as the responsible clinician confirmed them, with the date. Community providers act on this list, so remove risks that have resolved and say that they resolved. Note who the family should call if a risk changes after discharge.
7
Ongoing Needs and Onward Referrals
One row per continuing need: where referred, status and a contact.
More guidance
One row per need that continues after discharge, with where the patient is referred, the status (sent, accepted, waiting) and a contact. Typical rows include community or outpatient therapy, wheelchair or orthotic review, psychology, a return-to-work discussion, or a stroke or brain injury support group. Confirm each referral was actually sent before the summary goes out.
8
Recommendations After Discharge
Write actions the patient and family can take, referring to the home programme by date.
More guidance
Write recommendations as actions the patient and family can take: continue the home programme, attend the booked review, keep using the shower chair. Keep clinical recommendations to what the team has agreed. Refer to the home programme by its date instead of repeating it, so the two documents never contradict each other.
9
When to Return or Seek Review
Tell the family which changes should prompt a call, and how to re-refer.
More guidance
Tell the family when to contact the centre or another service: a change in walking or self-care over a week or two, another fall, new difficulty eating or drinking, or a new goal such as returning to work. Explain how to re-refer and whether a review is already booked. Families keep this page, so write it directly to them.
10
Copies Sent To
Tick each recipient, date it, and confirm the patient agreed to each one.
More guidance
Tick each person who received a copy and note the date. Confirm the patient has agreed to each recipient, especially an employer. Families often want a copy to share with relatives; give them the final reviewed version so an earlier draft does not circulate.
Rehabilitation discharge summary format and example: 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
Planned discharge home on 12 April after a six-week inpatient programme. Two of four shared goals achieved; the remaining two handed over to community physiotherapy and outpatient speech therapy.
Rehabilitation Episode
Six-week inpatient programme: daily PT and OT, SLT three times a week, psychology twice a week. Wife attended 10 carer training sessions. OT and PT home visit on 20 March; two supervised outings to the local market.
Outcomes Against Shared Goals
Goal 1: walk from bed to bathroom at night with walker, wife standing by. Start: one person steadying at hips. Discharge: standby help on 7 of 7 recorded nights. Outcome: achieved.
Function at Discharge
Self-care and daily living: washes upper body seated without help; needs his wife's help to wash his legs and put on trousers; uses a shower chair and a long-handled sponge.
Equipment, Home Changes and Carer Training
Wife trained in standby help for walking and toilet transfers; demonstrated safely on 8 April. Paid attendant Mr V. trained in the same on 9 April. Family bought a shower chair. Grab rail fitted beside the toilet on 18 March.
Risks and Precautions at Discharge
Falls: standby help for all walking at night. Swallowing: follow the SLT mealtime advice sheet dated 10 April. Both confirmed by the treating team on 11 April.
Ongoing Needs and Onward Referrals
Need: continued stair practice. Referred to: community physiotherapist near son's home. Status: accepted, first visit 18 April. Contact: number on the referral letter.
Recommendations After Discharge
Continue the home programme dated 11 April and take it to the first community physiotherapy visit.
When to Return or Seek Review
Contact the centre if walking becomes harder over a week, if he falls again, or when he feels ready to talk about returning to the shop. A review appointment is booked for 12 July.
Rehab discharge summary vs medical discharge summary
Medical course, investigations, medicines, follow-up
Main reader
Family, community therapists, family doctor
Doctors and the family
Goals
Outcomes against shared rehab goals
Usually not covered
Format
Your centre's template
Your hospital's or centre's format
Tips and mistakes to avoid
Do
Book onward referrals before writing, so the summary records confirmed arrangements and named contacts.
Write the function section for a community therapist visiting the home next week.
Give the family a copy in a language they read, and talk them through When to Return.
If the patient moves to another city or the native village, check which services exist there first.
In healhab, a discharge summary goes through the same clinician review as other reports, and a correction creates a new version.
Avoid
Sending the summary with referrals still marked “to be arranged”.
Copying the admission risk list without checking what changed by discharge.
Writing “good recovery” instead of what the patient does now, and with what help.
Using abbreviations and internal names only your centre understands.
About this discharge summary
A rehabilitation discharge summary records the end of a team rehab episode: why it ended, which disciplines were involved, outcomes against each shared goal, function at discharge, equipment and carer training, current risks, onward referrals, and when to come back. This free template gathers the whole team's input into one summary for the patient, family and next provider.
At the end of inpatient, day or outpatient rehab
On transfer to another centre or community team
When rehab ends early, such as hospital readmission
When the family needs a record for a new therapist
Read more
The discharge summary travels further than any other rehab document: to the family doctor, a community therapist, and the family's folder for years. Write it for a reader who has never been inside your centre.
The key worker drafts it in the final week, and each discipline confirms its rows. It sits alongside the treating doctor's medical discharge summary. Book referrals, equipment and carer training first, so it records arrangements that exist.
Questions
What should a rehabilitation discharge summary include?+
The reason for discharge, the disciplines involved, outcomes against each shared goal, function at discharge by domain, equipment and home changes, carer training, current risks and precautions, onward referrals, recommendations, and when to seek review.
Who writes the discharge summary in a rehab team?+
The key worker or coordinator usually drafts it, each discipline confirms its rows, and the clinician leading the episode reviews it. The treating doctor writes the medical discharge summary separately.
Is there a standard discharge summary format in India?+
Hospitals and rehab centres in India use their own formats. This template covers what a rehab team typically hands over; check your centre's and any partner hospital's requirements and add what they ask for.
How is a therapy discharge summary different from a medical one?+
A therapy discharge summary covers function, goals, carer training, equipment and ongoing therapy needs. A medical one covers the medical course, investigations and medicines. Most patients leaving rehab benefit from both.
What if the patient leaves before the planned discharge date?+
Complete the summary anyway with the information available. Record the reason, which goals were in progress, what could not be arranged, and how the family can return or be referred on later.
Is there a rehab discharge summary example?+
Yes. Each section guide on this page shows a fictional sample entry, using initials only. Use it to judge the level of detail, then write from your own team's records; goal outcomes are for the treating team to judge.
