Documentation Essentials Part 07: Discharge Summaries


Intermediate Level: Regardless of your payor source, a therapy plan of care cannot be closed without a proper discharge note. It is the clinician’s final opportunity to justify the services provided, demonstrate progress, and provide closure to the “story” of the patient’s treatment. This course provides the required documentation components of discharge from therapy services, including requirements set by Medicare B, as well as important tips on how to capture medical necessity and skills of the therapist.

Course Goal and Learning Objectives

To provide the steps necessary for writing an appropriate discharge notes in accordance with Medicare B regulations.

Upon completion of this course, the learner will be able to

    • Identify the six (6) essential components of a discharge note.
    • Identify who, as stated in the Medicare guidelines, is the appropriate practitioner required for compliance to write the discharge note.
    • Identify documentation pitfalls to avoid regarding writing a discharge from therapy services.
    • Identify a Medicare acceptable discharge note for a Medicare B beneficiary receiving therapy services.

    Click here for information about the Course Instructor, our consultant/subject matter expert and contributing author.