Conclusion of a single episode of care may not, in many settings or circumstances, signal the end of a patient or client provider relationship. The purpose of the conclusion of care summary is to summarize a patient's or client's progress toward goals, the individual's status at the end of the episode, and future plans for self-management. Essentially, this is the last opportunity a PT has to convey the outcome of physical therapist services. It is also a time to justify the medical necessity for the episode of care. Medicare requires that discharge summaries include all progress report elements. The purpose of the conclusion of care summary is to summarize a patient's or client's progress toward goals, the individual's status at the end of the episode, and future plans for self-management. Essentially, this is the last opportunity a PT has to convey the outcome of physical therapist services. It is also a time to justify the medical necessity for the episode of care. Medicare requires that discharge summaries include all progress report elements. Return to Elements of Defensible Documentation.

It is the position of APTA and many state policies and payer regulations that only physical therapists can complete the conclusion of the episode of care summary. The conclusion of the episode of care occurs based on the PT's analysis of the individual's achievement of the goals and outcomes. Important concepts to include in the conclusion of care summary are current patient or client status; attainment of goals; goals that have not been attained; and recommendations and instructions that were provided to the individual and/or caregiver such as home program, equipment provided, and training or other education. When a patient or client is discharged to another level of service, such as from an acute setting to home health or another inpatient setting, evidence of coordination of care should also be included. Issues related to patient or client adherence also may be noted as well as the number of completed visits. A conclusion of the episode of care summary should comment if the patient or client stops coming to physical therapy against recommendation of the PT. If the care of the patient or client is concluded prior to achievement of goals and outcomes, there should be documentation as to the status of the individual and the rationale for discontinuation.

For pediatric patients and clients:

In pediatric early intervention, a discontinuation summary is typically written in the format of a transition report, which provides information on the patient's status and progress during birth-to-age-3 services as the child transitions to preschool services under Part B of the Individuals with Disabilities Education Improvement Act. In school-based practice, the closure of physical therapist services is termed discontinuation of services, consistent with IDEA legislation. The decision is reflected in the IEP. Written documentation of the discontinuation should include a summary of the student's progress, the current status, and the rationale for discontinuing services. Discontinuation summaries in both early intervention and school-based programs typically also provide recommendations for community resources to support the pediatric patient's continued health, fitness, development, and well-being. In both early intervention and school-based practice settings, a decision to conclude the plan of care/discontinue physical therapist services is decided between the PT and the team. The decision is related to whether physical therapist services are needed to support the patient's and family's outcomes on the IFSP in early intervention or on the patient's goals on the IEP in school-based programs.