Discharge Summary and Administrative Discharge

When discharging a patient case, you have two options that function similarly to 1.0:

  1. Discharge Summary: use this note to document the patient’s last visit and bill for the visit.
  2. 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

  1. When you’re ready to discharge the patient case, open the (...) and select Discharge. 
  2. Answer the following question “Is this note the result of direct patient interaction during a clinical encounter.” 
    1. Select Yes to complete a Discharge Summary note and bill for the visit. 
    2. Select No to complete an Administrative Discharge note, which does not have a billing section.

Discharge Summary

  1. In this example, we’ll complete a full discharge and bill for the visit, so we’ll select Yes and click Apply.
  2. Date of Visit and Date of Discharge are required.
  3. You’ll need to update or click Add to Note for the Patient Presentation subsection.
  4. For Medicare patients, you’ll need to update or click Add to Note for the Standardized Test subsection.
  5. In the Plan section, expand the Discharge Summary subsection and complete the information.
  6. Update your Charge Summary to accurately bill for the visit.
  7. When we’ve completed and signed the note, the patient’s case will have a D/C indicator next to the case name. 
  8. 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 Discharge

  1.  If the patient does not return to therapy and you would like to discharge their case, open the (...) and select Discharge. 
  2. Choose No and click Apply.
  3. 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.