Occupational Therapy Discharge Note Example

A strong Occupational Therapy discharge note must document the patient's transition from the initial plan of care to their current functional status. Key sections include a summary of interventions provided, a comparison of initial and final standardized test scores (such as the DASH or Barthel Index), and a clear statement on whether short-term and long-term goals were met. It should explicitly detail the patient's ability to perform Activities of Daily Living (ADLs) and provide a concrete discharge disposition, such as a return to independent living or a referral to home health.

Using Aduvera to draft these notes removes the burden of recalling specific functional gains from memory. Instead of starting with a blank template, the AI scribe captures the nuances of the final encounter—such as the patient's demonstrated independence with a specific tool or movement—and organizes it into a structured format. This allows the therapist to focus on the clinical validity of the discharge summary through transcript-backed review rather than manual data entry.