Discharge Summary & Home Program
A complete record of your physical therapy episode of care, the gains made, the home program to maintain them, and what to do if symptoms return.
Total sessions delivered:
Treatment period (e.g. "10 weeks"):
Initial presentation, treatment delivered, and overall response across the episode:
Outcome Measure Final Scores
Measure 1: Baseline: Discharge:
Measure 2: Baseline: Discharge:
Residual deficits or asymmetries to monitor:
Functional Status at Discharge
What you can do now / what still requires care:
Return-to-work / sport status:
For each exercise: name, sets / reps, frequency per week, and cue notes.
Exercise 1 — name: Sets/reps: Frequency:
Exercise 2 — name: Sets/reps: Frequency:
Exercise 3 — name: Sets/reps: Frequency:
Exercise 4 — name: Sets/reps: Frequency:
Exercise 5 — name: Sets/reps: Frequency:
Exercise 6 — name: Sets/reps: Frequency:
Exercise 7 — name: Sets/reps: Frequency:
Exercise 8 — name: Sets/reps: Frequency:
Exercise 9 — name: Sets/reps: Frequency:
Exercise 10 — name: Sets/reps: Frequency:
Exercise 11 — name: Sets/reps: Frequency:
Exercise 12 — name: Sets/reps: Frequency:
Activity Modifications & Pacing
How to pace yourself, modify aggravating activities, and progress load over time:
Return-to-Sport / Work Criteria
Objective criteria to meet before full return — e.g. single-leg hop symmetry, lift capacity, endurance benchmarks.
Posture, ergonomics, warm-up, periodization, and lifestyle factors:
Red Flags / When to Return
Sudden severe pain, neurological signs (numbness, weakness, bowel/bladder changes), unexplained swelling — contact us or seek urgent care.
Booster session schedule (e.g. "1 visit at 6 weeks"):
Check-in via phone or video call:
Next appointment date (if planned):
Community group / fitness facility:
Satisfaction with PT care (1-5):
Would you recommend this clinic?
Testimonial (optional — what stood out about your care?):
What worked, what to apply next time, and any clinical pearls from this episode:
Patient signature (printed name):
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Discharging PT signature (printed name):
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Congratulations on completing your physical therapy. Keep the home program steady, listen to your body, and reach out if anything changes — we are here when you need us.