What must be included in the documentation for discharging a patient?

Documentation for discharging a patient is critical in ensuring continuity of care and legal compliance. Including the findings of the final evaluation and discharge instructions is essential because it provides a comprehensive overview of the patient’s status at the time of discharge. This information helps other healthcare providers understand the patient’s progress, necessary follow-up care, and any ongoing treatment requirements.

Final evaluation findings summarize the patient's condition and functional abilities, which are crucial for future care considerations. Discharge instructions are equally important as they guide the patient on what to expect after leaving therapy, outline any home exercise programs, state when the patient should return for follow-up, and provide any specific precautions or recommendations. Thorough documentation reflecting both of these elements contributes significantly to the patient’s safe transition out of care and helps prevent any misunderstandings or gaps in treatment that may arise in the future.