Discharge / Transition Plans &Discharge Plans

KNR 279Shank & Coyle, 2002Stumbo & Peterson, 2004

P IN SOAP

Additional information that is needed

Referrals Specific program (freq. & duration) New BO Interventions & facilitation When to reevaluate

DISCHARGE / TRANSITION PLAN

Should begin upon admission Purpose is to support successful

transition to community living or alternative placement Criteria for discharge

Where live after discharge? What services available there? What is the ultimate leisure goal?

DISCHARGE NOTE (or Discharge Summary)

Final component of client’s record Provides continuity to tx. plan &

summary of services D/C plan may go to agencies where

client is referred May not be legally required but our

professional standards require

DISCHARGE NOTE CONTENT

Each agency has own content & format Narrative Standardize forms or checklists SOAP

Use SOAP for class (OAP)

DISCHARGE NOTE CONTENT

O Major problems or goals

Related to leisure Reason for referral to TR Significant findings from TR assessment

TR services received by client Types, frequency, duration

Response to services Goals achieved Summary of previous progress notes No new information

DISCHARGE NOTE CONTENT

A Remaining problems on discharge Related to leisure

DISCHARGE NOTE CONTENT

P Plan for post D/C leisure involvement Reflects future residence Referrals to agencies Information or materials given to client

or family Handouts Adaptive equipment Resource contacts