Why You Should Request a Discharge Summary from Your OT

Occupational Therapy and Discharge Summaries

Occupational Therapy and Discharge Summaries. GettyImages

If you’ve been participating in occupational therapy, you’ve invested time, energy and, money in your health. If you fail to receive a written discharge summary from your OT, you may not get a full return on that investment.

Over the course of evaluation and treatment, your OT carefully recorded your progress. When discharge drew near, your OT documented recommendations for safely transitioning from OT services.

Ideally, during your last session, you should receive a written summary of your progress and your OT’s recommendations. Your care team should also forward a discharge summary to your next facility. When applicable, your care team should help you convert the recommendations into doctor’s orders, for example:

  • Patient requires one person to assist with self-cares.
  • Patient requires a commode in the home setting.
  • Patient will benefit from an OT evaluation for home safety.

Unfortunately, thorough discharge communication does not always take place. A new study published about our sister profession, physical therapy, confirmed what those of us working on the front lines in therapy already knew: often therapy recommendations do not get passed to the next care facility.

The study, published in 2015, followed patients from a large academic hospital with a chronic stroke center. The researchers found that physical therapy recommendations for patients transitioning to sub-acute care facilities were omitted from discharge orders at rates of 54%-100%.

These recommendations contained valuable information, such suggestions for patient safety, mobility assistance, and assistive devices.

Why Is Poor Discharge Communication a Problem?

You always have the right not to follow-through with therapist recommendations, but this should be a choice, not an oversight.

Failure to relay recommendations can result in the following:

Not obtaining the full value from the service

You, your insurance, or the facility is paying for the time your therapist invested in documenting your progress and discharge recommendations. This investment is for naught if they are filed away never to be seen again.

Redundancy

Without documentation of what you’ve accomplished in occupational therapy, there is a chance that the next round of therapy will duplicate services you’ve already received. They may even re-try techniques that have not worked in the past.

In worst-case scenarios, readmission

Say that OT recommends you receive assistance from at least one person when performing self-cares. If you transfer to a new facility and they do not receive this recommendation and provide this assistance, you may be at risk for a fall or other injury. In the aforementioned study, the researchers found that patients whose orders contained PT recommendations had a lower 30-day readmission rate—18% versus 26%.

What Your Discharge Summary Should Include

The American Occupational Therapy Association recommends that a discharge summary should include the following information:

  • Summary of your functional status
  • How long and how frequently you received occupational therapy services
  • What your treatment entailed
  • Recommendations for
    • Level of assistance needed with daily tasks
    • Home exercise program
    • Recommended assistive devices
    • Recommendation for further occupational therapy

Here is an example of a discharge summary. The summary may look different depending on whether you have seen an OT in a hospital, school, outpatient clinic or behavioral health center, but therapists in all settings should be able to generate a summary for you.

Advocate for Recommended Care

With a discharge summary in hand, you can advocate to receive the services and assistance recommended by your occupational therapist.  You can double check that all recommendations and orders are forwarded to and carried out by your next facility.

Even if you do not receive occupational therapy following discharge, it may be helpful to hold onto the summary in case you have cause to visit an occupational therapist at a later date. The discharge summary can serve as a handy tool for going over your history.

If you were not given a discharge summary, you can always go back and request a copy. You may need to sign a release form, but the effort may be well worth it.  

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