PERMISSIONS REQUIRED: You need the Docs permission to write a document.
Write a discharge summary when a patient is no longer continuing therapy. When this type of document is signed, the patient will be automatically discharged. The patient's goals will also be archived, so make sure the daily notes for the patient case have been completed before you sign the discharge summary.
NOTE: When a discharge summary is completed, all future appointments associated with the same patient case for that patient will be deleted.
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Edit a Document
Once you have opened a document to edit, there are a few basic mechanics to help you navigate and make changes throughout the document.
If there is any section you do not want to use, leave it blank and it won't be shown on the final document.
Navigate between Sections
To quickly scroll down to a specific section in the document, click the section's tab to the left.
Edit and Save a Section
To start editing the information in a section of a document, either click the section's Edit button or click anywhere in the section.
When you're finished making changes, click the Save button at the top of the section to save it. The section will also save automatically if you click in a different section on the document.
Pull Forward from a Previous Evaluation
You can click the Pull Forward button above most sections to copy information from a previous evaluation.
- Information will be copied from the most recent evaluation where that section was used. For documents linked to an appointment, the appointment's visit date is used. For documents not linked to an appointment, the document's created date is used.
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The Pull Forward buttons will only pull forward content from previous, signed documents for the same patient case.
- Make sure any information you pull forward is updated to reflect the current treatment session before you sign the document.
Use a Quick Phrase
You can use quick phrases that your clinic has set up to quickly insert commonly-used text into a field. While typing in a field, type a period followed by the short phrase to bring up the quick phrase list.
Appointment
Fill in the basic information about the appointment:
- In the Appointment field, you can select or change the appointment the document is linked to. An appointment is not required for progress notes.
- In the Time field, you can fill in the time the session actually began and ended. If you have already filled this in on the daily note linked to the same appointment, you can click the Copy icon
to bring over that information.
- The Case field indicates what patient case the document is associated with. You cannot change a document that has been started to a different case or to an appointment for a different case.
Diagnoses
The diagnosis codes on an evaluation are automatically copied from the patient's current diagnoses. Any changes made to diagnosis codes here will update the codes on the patient when you sign the document.
Questionnaire
Answer the questions you want to appear on the final document and write a summary of any final instructions you want to provide to the patient.
Outcome Measures
Select any of your clinic's outcome measures that you want to use to record the patient's baseline or changes in functioning, activities, or participation.
Tests & Measures
Select any of your clinic's tests or other assessments to record test results from this evaluation.
Performance Skills / Findings
Select from Performance Skills (for OT) or Findings (for PT, ST, VT, PS, TH, and CM) to record the patient's strengths and weaknesses for specific skill areas based on your assessments.
Areas of Occupation / Functional Measures
Select from Areas of Occupation (for OT) or Functional Measures (for PT) to record how the strengths and weaknesses identified in the previous section impact specific aspects of the patient's daily life.
Clinical Impressions
- In the Summary section, you can record the overall summary of your assessment findings and discharge instructions.
- In the Patient Education section, describe any information or education you've provided to the patient or caregivers.
- In the Home Activities section, choose whether or not to include home activities that have been linked to the patient's previous daily notes for a given period of time.
Goals
Only the goals for the patient case associated with the document (or appointment) will appear.
In the Options section, choose the time frame for goal data to include in the document and whether or not to include graphs.
In the Included Goals & Notes section, record any comments you have about the goals and choose whether or not each goal should appear.
Default Goal Visibility
By default, a discharge summary will show goals that include data in the selected time frame, even if that goal has been archived or mastered.
Contributors
Before you sign a document, you can send it to a contributor when another therapist needs to edit or add to it. For more information, check out the Send a Document to a Contributor help article.
Sign the Document
When you have finished working on a document, click the Sign button in the lower right to add your signature and complete it.
| Field | Description |
| Document Name | If needed, choose an alternate document name that will appear on the final document and in the list of completed documents. |
| Co-Signer | If the primary therapist doesn't have the Signoff permission, you can send the document to a co-signer. If present, this field is always required for evaluations. |
| Revision Reason | Explain why the document had to be revised and what changed. A log of revision reasons is kept so it can be provided to payers if needed. This only appears if the document has been revised and the clinic's Document Revision History is set to "Detailed". |
| Sign Date | The date this document was originally signed. |
| Password | Type in your password. |
If any drafted documents with a future date exist for the patient, a message will appear to let you know that the patient can't be discharged automatically. You can either sign the document anyway and manually discharge the patient later or cancel and clean up their future-dated document drafts first.