Discharge Summary and Administrative Discharge

When discharging a patient case in SOAP 2.0, providers have two options that function similarly to 1.0. In addition, clerical users can use the Administrative Discharge to discharge a case when necessary.

• Discharge Summary: Providers can use this note to document the patient’s last visit and bill for the visit.
• Administrative Discharge: Both Providers and Clerical users can use this option when a patient self-discharges and does not return to therapy for their final visit. This is a non-billable note.

Discharge Summary - Provider

Typically Providers discharge a case at the end of the patient’s treatment, once all other notes have been completed on the case.

1. From Patient Records, click (...) and select Discharge. 
   

2. If the discharge note is the result of direct patient interaction during a clinical encounter select, Yes.

   

   Note: If the note is not the result of a direct patient interaction continue to the Provider Administrative Discharge section.
3. Click Apply to begin the Discharge Summary note and bill for the visit.

Complete the Discharge Summary

To complete the Discharge you will need to also complete the Discharge Summary and bill for the visit.

1. Add the required Date of Visit and Date of Discharge and check the box to Remove future appointments if you would like to remove all future scheduled appointments for the patient.

   

2. You’ll need to update or click Add to Note for the Patient Presentation subsection.
   
3. For Medicare patients, you’ll need to update or click Add to Note for the Standardized Test subsection.
   
4. In the Plan section, expand the Discharge Summary subsection and complete the information.
   
5. Update your Charge Summary to accurately bill for the visit.
6. When we’ve completed and signed the note, the patient’s case will have a D/C indicator next to the case name. 
   
   Note: If you chose to delete all future appointments, you’ll also see a confirmation on the case records page.
7. 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.

Administrative Discharges

Administrative Discharges can be completed by a provider or a clerical user when a patient does not return to therapy.

Provider Administrative Discharge

1. Providers can also create an Administrative Discharge from the patient Record, open the (...) and select Discharge.

   

2. If the discharge note is not the result of direct patient interaction during a clinical encounter select No, t

   then click Apply and complete the Administrative Discharge note (this does not have a billing section).

   

3. Add the required Date of Discharge and check the box to Remove future appointments if you would like to remove all future scheduled appointments for the patient. Then complete and sign the note. The case will be discharged in SOAP 2.0 and 1.0.
   
   Note: If you chose to delete all future appointments, you’ll see a confirmation on the case records page.

Clerical Administrative Discharge

1. Clerical Users can create an Administrative Discharge from the patient Record, open the (...), and select Administrative Discharge.
2. Add the required Date of Discharge, and check the box to Remove future appointments if you would like to remove all future scheduled appointments for the patient. Then complete and sign the note.

   

3. Once the note is completed and signed, the case will be discharged in SOAP 2.0 and 1.0.