OT Discharge Note Example and Drafting Guide

A strong OT discharge note must clearly bridge the gap between the initial evaluation and the final status. Key sections include a summary of the treatment duration, a comparison of baseline vs. discharge scores for standardized assessments, and a detailed list of achieved goals. It should explicitly document the patient's current level of independence in ADLs, the specific durable medical equipment (DME) provided, and a clear discharge disposition—whether the patient is returning home, moving to a skilled nursing facility, or transitioning to home health.

Using Aduvera to draft these summaries eliminates the need to manually parse through weeks of session notes to recall specific patient quotes or functional milestones. By recording the final encounter, the AI captures the patient's self-reported outcomes and the therapist's final clinical impressions in real-time. This creates a high-fidelity first draft that ensures no critical discharge instruction or functional gain is omitted, allowing the clinician to focus on verification rather than manual data entry.