Types Of Occupational Therapy Documents PDF

Types of Occupational Therapy Documents  Clinical Documentation typically consists of summary of the evaluation results documentation of progr...

Types of Occupational Therapy Documents  Clinical Documentation typically consists of summary of the evaluation results documentation of progress, documentation of the client’s (including the occupational profile attendance records, discharge intervention plans, referral for services, and analysis of occupational summaries, and follow-up performance), documentation (if any). Regardless of the type of clinical documentation, certain conventions for good documentation must be followed all documentation must be well-written, accurate, and clear.  In essence, for each step of the occupational therapy process there is documentation to go with it. Client Identification: Referral and Screening  suggestion from someone that a Referral particular client would benefit from occupational therapy services Screenings Often, but not always, a screening occurs at the first meeting of occupational therapist and client. A screening is a brief, hands-off check of a client to see if further evaluation or intervention is warranted It is often based on observations of a client and chart review without the direct intervention of an occupational therapy practitioner.  Client does not need intervention right now, but there is enough Client may, in fact, concern that it would need occupational be worth rescreening therapy intervention Possible in a few months (or whatever period you think is appropriate) Outcomes of Screening Client needs a referral to some other Client may not need any intervention at all professional Evaluation Reports  To describe a client’s current level of performance Main Purposes for Doing To select interventions and Evaluation predict outcomes (Bass- Haugen, 2010) To build theory that supports occupational science and occupational therapy  Evaluation Establish baseline from Describe unique which future Predict future function circumstances of client’s performance can be through goal setting situation measured and compared The Process Intervention Occasionally, an Evaluation serves as documentation of a client’s function at that point in time. evaluation is completed and no If another evaluation is completed at a later date, it can be compared to the intervention previous evaluation, to see if functional skills have been gained or lost. is needed.  “the client’s engagement in occupations to support participation in the community or in organizations.” (Moyers & Focus of Dale, 2007) Evaluation process finding what identifying the client wants those factors to do, needs to that support or do, used to do, inhibit and can do; performance.  Top- considers occupational roles and performance first and then discerns the factors that contribute to the Down occupational performance (Stewart, 2001; Weinstock- Zlotnik & Hinojosa, 2004). specific tasks that a person will need to do or wants to do are considered first; the specific “foundational skills (performance skills, performance patterns, context, Approaches activity demands, and client factors) are considered later” (Weinstock-Zlotnik & Hinojosa, 2004, p. 594). to Bottom- foundational factors are evaluated first; then Evaluation Up occupational performance is addressed (Weinstock- Zlotnik & Hinojosa, 2004). calls for an examination of a client’s assets and limitations first, under the assumption that, as the limitations are eliminated, reduced, or compensated for, the occupational performance will naturally improve (Weinstock-Zlotnik & Hinojosa, 2004).  NOTE! 01 02 03 It is important to base It gives you a starting The model or frame of reference will guide the critical thinking of one’s evaluation point and direction in the occupational therapist in the process on a particular which to proceed. selection of evaluation methods and assessment tools, as well as model or frame of the language by which the reference. occupational therapist will describe occupational performance strengths and deficits.  Evidence-based Practice Client-centered Practice to the extent possible, you Client is a full partner in the must be prepared to show evaluation process (Law, that your interpretation of the Baum, & Dunn, 2001). data collected and plan for client’s subjective intervention are supported by experiences, as well as the both the client’s needs and occupational therapist’s research. objective observations and measurements, are both critical to the evaluation Contemporary process. establishment of occupational OT Practice therapy outcomes (goals) is a collaborative effort between the client and occupational therapist. client’s subjective experiences are reflected in the occupational profile, and the objective observations and measurements are reflected in the analysis of occupational performance (AOTA, 2014). Philosophical and Theoretical Influences on Evaluation Process (Hinojosa & Kramer, 2010) evaluation process is data collected should “shed assessment tools can have client’s perspective, as well evaluation process is based ongoing throughout the light on how to facilitate biases and so can the as that of the client’s family on relevant theories and service delivery continuum engagement in personally people who administer and caregivers, is frames of reference and it is a dynamic and meaningful activities and them incorporated into the (Hinojosa & Kramer, 2010). interactive process. occupations that will fulfill evaluation process life roles” (Hinojosa & Kramer, 2010, p. 25). Steps in OT Evaluation Process Components of an Evaluation Report Identification Information (client Person making the Type/amount of Reason for referral Date of referral name, date of birth, referral service requested gender, diagnoses) Analysis of Precautions and Occupational Initial intervention Assessment tools occupational contraindications profile plan* profile  Occupational Profile occupational therapist describes the “client’s occupational history and experiences, patterns of daily living, interests, values, and needs” (AOTA, 2014, p. S13). occupational therapist is trying to understand, from the client’s perspective, what the client requires using a client-centered approach. wants and needs. occupational therapist needs a solid understanding of the client’s past experiences and contexts, current occupational strengths and areas that are problematic, and priorities/desired outcomes (AOTA, 2014) discussing the client’s situation with him or her helps to build rapport and establish a therapeutic relationship necessary for collaboration with the client throughout the occupational therapy process (AOTA, 2014).  performance skills, performance focus of the analysis is on gathering patterns, client factors, and and interpreting data from contexts that affect occupational assessment tools Analysis of performance are identified and prioritized. Occupational Performance important to note that the occupational profile and analysis of occupational performance may be performed sequentially or concurrently (AOTA, 2014).  1. Observation of occupational performance Gathering 2. Interviewing the client of Data for and the client’s caregivers an Evaluation 3. Selecting, administering, and interpreting assessment tools Writing the Report  Descriptive statements are objective describe what you can see, hear, taste, touch, or smell Descriptive, Interpretive statements Interpretive, based on observations or data, but draw some inference or conclusion about the observation Evaluative or data. Statements Evaluative statements pass judgment on something; obvious that the person making the statement feels good or bad about it, satisfied or dissatisfied, angry or accepting. Reporting Data and Interpreting It Reporting data means providing objective, factual information, while interpreting data means drawing an inference based on the objective (reported) data. Recording raw test scores or direct observations is reporting data. Taking those raw scores and using the scoring manual to get a t-score or age equivalent is interpreting the data. Drawing conclusions about what you saw is interpreting it.  ongoing process At every intervention session, the occupational therapy practitioner makes observations, collects information about changes in the client’s circumstances and performance, and sometimes makes adjustments in the intervention methodology Re- may be formal or informal evaluation Informal reevaluation occurs every time the occupational therapist revises the intervention plan A formal reevaluation may involve repeating previous testing so that changes in performance can be measured and documented. Often formal reevaluation occurs when a client is close to being discharged or at regular intervals, such as yearly for a child with developmental delays. Re-evaluation As a Three-Step Process (Nielson, 1998) Data collection Reflection Decision-making involves gathering subjective is a thought process centered the occupational therapist and objective information on the client’s current status, decides whether the current relative to the targeted changes in status since the last intervention plan is sufficient, outcomes identified by the evaluation, and a judgment on whether it should be changed client and clinician. the effectiveness of the current in some way, or whether the intervention plan. client is ready to be discontinued from occupational therapy services Intervention Plans  Intervention Plan 01 02 03 04 where the occupational based on the results of development and revision tells the occupational therapist articulates the evaluation and the are a collaborative effort therapy practitioners what expected outcomes and wants and needs of the between the occupational they are going to do to how they will be achieved. client or surrogate (i.e., therapist, the help the client. parent or guardian) occupational therapy (American Occupation assistant, and the client Therapy Association (AOTA, 2010a). [AOTA], 2010a).  Establishing goals and determining intervention strategies that will be effective, and that third-party payers will pay for, is critical to the ongoing viability of your practice in occupational therapy. If you do not get paid for what you do, you will not be able to make a living at being an occupational therapy practitioner. To be paid for your services, you have to show that the intervention made a difference in your client’s life. That is what motivates us to become occupational therapy professionals in the first place— we want to help make people’s lives better.  Concepts for Intervention Planning To help your client make This requires knowledge of progress toward his or her both the skills and abilities of desired outcomes, you must your client and the qualities select intervention strategies of the activities (occupations) that will lead your client in so that there is a match the same direction as the between what the activity has to offer and what the client mutually-agreed upon needs. goal(s).  Concepts for Intervention Planning An intervention plan is not engraved in stone; it is subject to change as the client’s condition and contexts change. If the occupational therapist believes that a change in the goals or intervention strategies, including the frequency, intensity, or duration of intervention sessions, is needed, he or she writes up a new intervention plan. Factors to consider when changing the frequency or duration include client’s potential to benefit from services, the degree of dysfunction, outcomes research on clients with similar conditions and interventions, potential for caregiver follow-through, and possible complications that could change the client’s rate of progress (Moyers & Dale, 2007). Intervention plans are established as soon as the occupational therapist determines that the client needs intervention and may be reviewed every 30 days, 60 days, quarterly, or semiannually (twice a year), depending on the setting, the needs of the client, and the demands of the payer.  Concepts for Intervention Planning The intervention plan must consider not only the client’s goals, skills, abilities, and deficits, but also the In addition, the occupational therapist client’s values, beliefs, current and must use the best available evidence in desired state of health and well-being, determining the best course of action contexts and environments of the for the interventions. client and the setting in which the intervention will occur, and activity demands (AOTA, 2014).  The first intervention If it is part of the However, if it is a plan you write for evaluation report, then stand-alone any one client might there is no need to document, then you be part of the repeat will need to include evaluation report, or identification/backgro the same kind of it may be a stand- und information. identification Parts of an alone document, information that you depending on the included on your Intervention policies of the facility at which you work. evaluation report (AOTA, 2013): Plan Client name, gender, and date of birth Date of the document (may be part of the signature) and the type of document; name of agency/facility and department Intervention diagnosis/condition and other diagnoses/conditions Precautions and contraindications Parts of an Intervention Plan what you hope to AOTA (2013) specifically Along with revising goals, The intervention accomplish in the next states that the short-term you must determine approaches are (AOTA, review period, adjustments goals must be “…directly appropriate intervention 2013, 2014): to the short-term goals, related to the client’s ability strategies and methods intervention strategies, or and need to engage in given the client’s current the duration, frequency, and desired occupations” (p. 5). condition and contexts intensity of intervention (AOTA, 2013). AOTA (2013, sessions can be made. 2014) distinguishes between intervention approaches and types of Create or promote intervention. Establish or restore Maintain Modify Prevent Parts of an Intervention Plan The people reading your intervention plans (other They have to see that if you set a long-term goal to facility staff, physicians, third-party payers, quality improve someone’s dressing skills, then the short- management personnel, lawyers, etc.) must be able term goals and methods of intervention must also to see the logical thinking that went into your plan. directly relate to dressing. Not everyone who reads your intervention plan will understand the link between improving dexterity and improving dressing, so if your intervention plan calls for stringing 14-inch beads, it will not make logical sense. If, however, your intervention plan calls for learning to don and doff certain articles of clothing with certain types of fasteners, it will make logical sense.  Parts of an Intervention Plan AOTA (2013) suggests that the service delivery mechanisms and plans for discharge be included in this section. Service delivery mechanisms include such details as who will provide the services, where the services will be provided, and the frequency and duration of services. The plan for discharge includes criteria for discontinuing occupational therapy services, discharge disposition (where the client will be discharged to), and the need for follow-up care. AOTA (2013) also suggests that the tools that will be used to determine outcomes be identified. Parts of an Intervention Plan The last part of the intervention plan is for signatures. Every intervention plan needs to be signed by an occupational therapist. The AOTA Guidelines for Documentation of Occupational Therapy Practice (2013) suggests including the name and position of each person responsible for overseeing the implementation of the plan. Each time you sign a document, always include the date it was written in the signature line. Summarizing Progress Generally, you will write an Between intervention plan On your initial intervention It is helpful to go back over It is important to give the intervention plan for a client revisions, you will write plan, you will not be able to the progress notes written reader an accurate picture every 30–90 days. progress notes. summarize progress, but on over the last month (or of progress. subsequent intervention whatever the interval plans you will. between plans is in your setting) while you summarize changes since the last intervention plan was written. Summarizing Progress Some words are “loaded,” that Choose your words carefully. is, some readers will twist them in ways you never intended “Continues to have difficulty with ______,” a payer might interpret it as “not making Understand how others interpret words. progress.” In reality, the client has made progress, but not as fast as you had hoped. Summarizing Progress  Summarizing Progress When you summarize progress over time, the focus needs to be on engagement in occupation. Describe the new occupations the client does now that he or she could not do last month (or whatever your time frame is). Focusing on function means making sure you address what the client does, not the underlying skills and abilities. Summarizing Progress How do you demonstrate By choosing words that On an intervention plan, it is To do otherwise would Evaluation reports can be progress? show change as much as not necessary to describe result in a lengthier long, but intervention plans possible while still being everything the client did document than you want to usually have limited space honest. over the past month; hit write and than anyone for recording progress. only the highlights, only wants to read. ones that directly relate to the goals you set last month.  What do you write if there has not been the progress you had hoped for? Explain what barriers to progress were encountered. Summarizing There is probably a reasonable explanation for maybe there was a medical complication or change in life Progress the lack of expected progress; circumstance that got in the way. Whatever the explanation, keep it simple and short. Explain how you will modify your intervention plan to encourage greater progress.  In some places, the payers allow maintenance therapy. In maintenance therapy, a client has a condition that is likely to cause functional deterioration. Summarizing Progress Occupational therapy intervention can delay or prevent this deterioration. If this is the case, showing progress is not expected; maintaining function is good. Do not try to describe progress when maintenance is the goal.  Documenting Intervention Strategies Once you and the client have reviewed progress to date and revised short-term goals toward which to work (the outcome or long-term goal is not likely to change, although under some circumstances it might), your thoughts can turn toward intervention strategies to use to help the client meet those goals. Strategies can include specific techniques for whether the client would intervention that are types of adaptive task/environmental be best served in an the manner in which you general principles for suggested by the model aids/assistive modifications that will be individual or group approach the client, intervention, or frame of reference technology, or tried (AOTA, 2013). session (Moyers & Dale, you are using, 2007). Documenting Intervention Strategies As you develop intervention plans, remember that problem identification (evaluation results), goal setting, and intervention strategies all have to relate directly to each other. One way to ensure this Specific intervention interrelationship is to use a techniques are usually frame of reference to guide explained by the frame of your thinking. reference you are using.  The way you approach the client should be specified in your intervention strategies section and could mean you identify… whether you approach the whether you approach the whether you approach the client like you are the expert client at bedside or in the client at eye level, or a partner in recovery, or clinic. Documenting Questions to consider Intervention Will you follow the client’s suggestions or will Strategies you be making suggestions? Will you be firm or flexible? Some of this will depend not only on the frame of reference, but also on the age and condition of the client and the philosophy of the program that is serving the client. Documenting Intervention Strategies Other information to record in the strategies section of the intervention plan includes the types of assistive Since your strategies are simply Then in the strategy section, you can technology, adaptive equipment, or descriptions of what you will try list several possibilities for different task/environmental modifications the during the plan period, you can types of equipment or different client will try and what home suggest many options. techniques. programs or training will be provided to the client or client’s caregivers. If you put the specific type of If the goal says that the client will do equipment in the goal statement, something with or without adaptive you get locked into using that equipment, you are freer to equipment. experiment. Documenting Intervention Strategies In addition to establishing goals and intervention strategies, the plan section includes the occupational therapist’s Along with this information, intervention plans specify the location of intervention sessions (e.g., bedside, clinic, and client’s recommendations on the frequency, home) and the anticipated environment to duration, and intensity of occupational which the client will be discharged (AOTA, therapy intervention sessions (AOTA, 2013). 2013). Documenting Intervention Strategies Why did you choose the goals you wrote down? How do they relate to the client’s needs? When you first start out writing intervention plans and client goals, it is not In most clinical settings, uncommon for your your rationale will be How do your To help you think about professor or supervisor to implied; there will not be ask that you specifically time or space to spell out your rationale, consider intervention strategies the following questions: relate to each goal? state your rationale for the This is actually a good your rationale on every goals you set and the way to start out because intervention plan. intervention strategies it forces you to articulate you suggest. why you made the choices you did. What frame of reference (or model of practice) guided your thinking? Were there goals or strategies that you considered, but chose not to record? If so,why?  Revising Intervention Plans This is not necessarily a sign that The longer you work with a particular client, the more likely it is your plan is not working, but it just that you will need to revise your intervention plan. means that it takes time to effect significant changes in a person. Intervention plans are usually revised on a regular schedule, such as every 30 or 90 days, often depending on the requirements of the third-party payer and/or the condition of the client. If it is working, then maybe the time Maybe you were too ambitious in is right to take things to the next your goal setting and need to set level. smaller goals. Revising the intervention plan allows you to step back from day- to-day intervention and really evaluate whether the plan is working or not. If it is not working, then this is a Maybe you were not ambitious good time to figure out what you enough and you need to set higher could do differently. goals. It is up to the occupational therapist to evaluate the effectiveness of the intervention plan. Maybe you need to consider taking the interventions in a whole new direction. Any changes in the plan should be made in consultation with the client and/or client’s caregiver (AOTA, 2010a).  Intervention Plan by payers to determine whether continued intervention is needed, by coworkers to communicate the client’s current status and It is a vital document that is used progress, by the occupational therapy personnel to evaluate the effectiveness of intervention programs Generally speaking, a client receiving ongoing Except when the client is working on maintenance goals, each intervention from occupational therapy will have an successive intervention plan should show progress in the client’s intervention plan developed immediately after the areas of occupation. evaluation, and then periodically until services are If progress is not made, an explanation for the lack of progress must be given. discontinued. Intervention strategies include frequency and duration of services, In addition to necessary client identification information, manner of service delivery, place of service delivery, types of intervention plans usually contain a brief summary of adaptive equipment/environmental adaptations, task progress, revised goals, and intervention strategies. modifications, home programs, and training for the client and the client’s caregivers. While intervention plans are written in ink, they are not They are expected to change as the client’s circumstances and engraved in stone. condition changes. SOAP and Other Methods of Documenting Ongoing Intervention  Documenting Ongoing Intervention Written documentation of ongoing intervention comes in In most cases, they are written following each different sizes and formats, but all are intended to intervention session; however, in some cases, they may provide a record of intervention sessions. be written weekly or at other time intervals. Progress Notes should be more than simply a listing of the types of activities in which a client has engaged. notes need to include information about the client’s response to interventions and how current performance is different from previous performance (American Occupational Therapy Association [AOTA], 2014; Brennan & Robinson, 2006). any unusual or significant event, assistive or adaptive equipment issued or tried, and any client/caregiver instruction also need to be documented (AOTA, 2014). has to show that the skills of an occupational therapy practitioner contributed to the progress a client has made toward the goals established in the intervention plan; how the client is different as a result of occupational therapy interventions (Brennan & Robinson, 2006).  Contact Notes intended to be shorter, and reflect the may be in any of the formats described in the Since this note reflects one session or one client’s response to intervention during that following sections, or in the form of a log or day’s sessions, the emphasis is not on day or that intervention session (Brennan & flow sheet. progress, but on what services were Robinson, 2006). provided and how the client responded to that intervention, including adaptive equipment issued, and any client or caregiver education provided (Brennan & Robinson, 2006).  Medicine’s acronyms Subjective – Objective – Assessment – Plan SOAP Quite common and reader knows just what kind of information to find in what part of the note Notes Professionals from all health care disciplines write them Format can also be adapted for use as an evaluation report or discontinuation summary (Gateley & Borcherding, 2012; Kettenbach, 2009).  Narrative Notes If the narrative progress note is written directly in the client’s medical record, it is usually done in a section of the medical record set aside for that purpose. Notes are entered as close to the time of intervention as possible since the notes are expected to be in chronological order. Written directly in the medical record need to be dated, and often the time the note was written is also recorded (Fremgen, 2011; Ranke, 1998). The length of time of the intervention session is usually recorded. Narrative Notes How do you show that your client is making progress? You have to show that You have to show a the client is doing change in the client’s something now that he occupational or she could not do performance before; Progress Flow Sheets can show the progress a client is making on typically tables or graphs where makes it easy for the reader to see at a specific activities in a very concise way. measurements can be recorded at regular glance whether progress is being made in a intervals, generally after each intervention particular area of need for a client. session. Progress Flow Sheets Advantages Disadvantages there is space makes it easy for enough to record There may be a a substitute instead of relying on someone saying a a number or other there is no place place to record easier to read clinician to know client has made progress, you have provide reliable data that can be used objective to record the new interventions, than multiple what to expect a solid, objective data that shows the to write progress summaries. measurement, but client’s reaction to but there may not contact notes. client to do in the progress. not room for the intervention. be, depending on next occupational descriptions of the form used. therapy session. performance. In those settings where progress notes are keeps the clinician written weekly or data recorded is kept contains a lot of data focused on biweekly, a clinician helpful if the client’s to a minimum, and is but uses minimal interventions that are who can reflect that medical record is ever organized in an easy- space, so it conserves specific to the client’s data off the flow sheet called into court. to-follow format. paper. goals, and less chance will have written a more to go off on tangents. reliable note than one who writes from memory alone. Attendance Logs many also identify which can be used for billing therapy occupational therapy personnel some also identify which type of may be kept on a clipboard in at minimum, identify when the services if it is designed to be worked with the client that day, intervention happened during the department with a separate client had therapy. compatible with the billing and how long the therapy which intervention session. page for each client. system used at that facility. session was. if used for billing, then the biggest difference between the when the client is discontinued, interventions are labeled so that can be set up much like the first attendance log and the flow may go in the client’s they coincide with billing codes. example of a flow chart, with sheet is the attendance log permanent record, the may also be built into an In the box that correlates to the date dates across the top and does not include any data on department file, or the billing electronic health record system. and intervention, the clinician records interventions listed along one the client’s performance, only office, depending on facility the number of billable units of that side. intervention, or the number of minutes that a particular intervention policy. of that intervention. was worked on. Discharge Summaries  When the client achieves all of his or her goals, moves out of the facility, refuses to continue in the program, or achieves maximum benefit from occupational therapy, a discharge summary must be written (American Occupational Therapy Association [AOTA], 2010).  Discharge Summary / Report needs to show the client’s progress from final justification of your services. the beginning of occupational therapy services to the end Components of a Discharge Summary In some facilities, the discharge There is one document and members of the summary is an interdisciplinary treatment team all contribute to the one effort. discharge document. At other facilities, there may be a paper or electronic form or format that is followed by each profession for discharge summaries. Generally, no matter whether you dictate, fill out a form, or write the report electronically, the same basic information is provided. Components of a Discharge Summary a good client is being discharged from These are good reasons to discharge the facility, is refusing further discontinue services. summary will therapy, or that the client has also include the achieved the outcomes expected. reason for discontinuation. client has reached the maximum This is not a good reason to insurance coverage, for example, discontinue services because it is not the client may have hit the cap on related to the client’s outcomes or wishes. Medicare outpatient therapy. if a client chooses to discontinue The difference between these is that services for financial reasons, that in the case of the payment limit, the may be a satisfactory rationale for decision to discontinue is being made by someone other than the client and discharge. occupational therapist. A client can choose to discontinue occupational therapy at any time and for any reason, but the documentation should reflect that it was the client’s choice, not a decision made for the client by the occupational therapist or the occupational therapist’s employer. Components of a Discharge Summary It is important to be If a client has been receiving However, if a client was seen comprehensive, yet concise occupational therapy for a few days to a few weeks, when reporting on progress intervention for several months you may address each short- toward goals and occupational or more, you may want to term goal. therapy outcomes. focus more on the long-term goals than on each and every adjustment to short-term goals.  When addressing the initial and ending status of the client in relation to engagement in occupations, the emphasis will clearly be on occupations rather than on changes in client factors, activity demands, or even contexts. Components However, contexts, especially those related to the client’s discharge disposition, are very important. of a Discharge The client’s discharge disposition is the place the client is being discharged to; it could be to the client’s home, Summary extended care facility, assisted living facility, home care, outpatient program, or other community-based service (Moyers, 1999). Your evaluation of the client’s ending status is dependent on the discharge disposition. Components of a Discharge Summary If a client is being discharged to his In order to make appropriate If a client is being discharged to If the client will be receiving or her home, community-based recommendations for follow-up or another facility, you need to know occupational therapy intervention at services can be recommended, but referrals in the discontinuation what services are available at that the new facility, it is helpful if the the occupational therapist has to summary, the discharge disposition facility in order to make an occupational therapists can talk with know what kinds of services are is also essential (Moyers, 1999). appropriate referral. each other. available in the area. You may recommend that the client come back in a few months for a recheck, for example, if you expect For any of these reasons or others, However, if you make such a the client will progress or regress on Orthotic devices or adaptive recommending the client come back recommendation, be sure it is his or her own and may need more equipment may need to be checked in three months for a recheck may documented in the discharge occupational therapy at a later time periodically for wear and fit. be a good idea. summary. or the client may have some medical procedures planned that will result in a change of functional status. Discharge Summary The discontinuation of services brings closure to a case. It provides the final justification for the services that were provided. In this document, you provide an overview of the client’s progress and plans for the future. Because it is a summary, it does not need to be a session-by-session recap of what happened. Rather, it hits the highlights and reflects progress toward occupational therapy outcomes. A discharge summary may be written in narrative or SOAP format. Either way, the discharge summary must contain specific information about the client’s change in status and recommendations for follow-up and referral to other services. Knowing the client’s discharge disposition is essential for making accurate statements about the client’s status at discharge and what services can be recommended after discontinuation of occupational therapy services.