Discharge Summary and Administrative Discharge
When discharging a patient case, you have two options that function similarly to 1.0:
- Discharge Summary: use this note to document the patient’s last visit and bill for the visit.
- Administrative Discharge: use this option when a patient self-discharges and does not return to therapy for their final visit. This is a non-billable note.
Important: All other notes must be finalized before a discharge can be finalized
- When you’re ready to discharge the patient case, open the (...) and select Discharge.
- Answer the following question “Is this note the result of direct patient interaction during a clinical encounter.”
- Select Yes to complete a Discharge Summary note and bill for the visit.
- Select No to complete an Administrative Discharge note, which does not have a billing section.
- In this example, we’ll complete a full discharge and bill for the visit, so we’ll select Yes and click Apply.
- Date of Visit and Date of Discharge are required.
- You’ll need to update or click Add to Note for the Patient Presentation subsection.
- For Medicare patients, you’ll need to update or click Add to Note for the Standardized Test subsection.
- In the Plan section, expand the Discharge Summary subsection and complete the information.
- Update your Charge Summary to accurately bill for the visit.
- When we’ve completed and signed the note, the patient’s case will have a D/C indicator next to the case name.
- The case will also be discharged in SOAP 1.0.
Remember: if you create a discharge note for a patient, and determine during the examination that they are not ready to be discharged, you can convert the signed note to a Progress Note.
- If the patient does not return to therapy and you would like to discharge their case, open the (...) and select Discharge.
- Choose No and click Apply.
- Date of Discharge is the only required field. Complete the note and sign. The case will be discharged in SOAP 2.0 and 1.0.
Don’t: Converting An Administrative Discharge
Important: We do not recommend converting an Administrative Discharge to a Discharge Summary. This is because no fields will carry forward from your last note. If you’d like to move from an Administrative Discharge to a Discharge Summary, we recommend deleting the Administrative Discharge and creating a new Discharge Summary note using the process described above.