Manage Patient Discharges

The following describes how to manage both planned and unplanned patient discharges using Charting and Letters features.

Patient Discharge Scenarios

There are three common scenarios to consider in discharging patients:

  • Planned discharges
  • Unplanned discharges
  • Discontinued treatment

Planned Discharges

When it is known at the time of the visit that this will be the final visit for the patient, the therapist may include information on goal progression and a discharge summary in the Progress Report.

The following is an example of a planned discharge scenario and how to respond to it. William "Fox" Mulder has been scheduled for a progress evaluation today. He will not be able to return for therapy and this is known at the time of the visit.

  1. Goals established at the initial evaluation are updated in the goal tracker. As you enter the current status for goals in your documentation, the updates will automatically populate in the goal tracker.
  2. Note: The only fields that need to be updated directly within the goal tracker are the Progress field showing whether or not the goal was met, and the Achieved On field showing when progress was assessed.

  1. A Discharge Summary report has been formatted for this purpose. You have the option to fax and/or print the Discharge Summary report from the Sign Chart Notes dialog box. Printing this visit information off as a Discharge Summary will automatically include needed information on number of visits, the date of the initial visit, and goal progression in the report.
  2. Note: The Discharge Summary report can also be printed by clicking the Print Icon within the Chart Tab and selecting Discharge Summary.

  1. Here is an example of the first page of a Discharge Summary:

  1. Here is an example of an automatically generated closing statement that can be configured in the Print Layout Templates section:

Unplanned Discharges

When it is known some time later that the patient is being discharged from therapy, there are two options for creating a discharge report:

    • Updating documentation from the last visit to include additional information about the discharge, including goal progression and a discharge summary.
    • Creating and using a preformatted discharge summary letter.

The following is an example of an unplanned discharge and how to respond to it. William "Fox" Mulder was making good progress after several visits, but his insurance benefits for physical therapy have been maxed out. He calls to explain that he cannot return to therapy. His last visit was one week ago. He has been making adequate progress toward goals established at the initial evaluation and under different circumstances would have continued therapy.

Option 1: Updating Documentation from Last Visit

  1. Edit the documentation for the latest visit. In this example, the patient was making adequate progress and the therapist has been tracking goal progress.

  1. To update the latest note, click the Lock Icon to unsign it and add additional information. You will be required to enter a reason for unsigning, as well as your INSIGHT password.

  1. One method of updating the information is to add a general summary statement by right clicking the Summary Area in the topic tree.

  1. The following is an example of use of a summary to update the documentation for a prior visit.

Option 2: Discharge Summary Letter

The second option for creating a discharge report is using a Discharge Summary letter, as illustrated below:

Enter free text that that is intended to update the referring physician. Yellow indicates free text added to the letter.

Discontinued Treatment

If the patient has quit coming to therapy, you may elect to produce a Discontinued Treatment letter. The following is an example of discontinued treatment and how to respond to it.

William "Fox" Mulder hasn't come back since his initial evaluation 3 weeks ago and hasn't returned numerous phone messages. There is no new clinical information to report since his initial evaluation.

Open the patient's Client Editor or select the Letter Icon to create a Discontinued Treatment Letter for the patient.

The Discontinued Treatment Letter makes it easy to report to physicians that there is no new information and that the patient is discharged. You can save this letter to the patient's record or your computer, fax it to a provider, or print it as necessary.

Click here to move×