OAR 848-040-0170: Standards For Discharge Records

(1) Within 30 days following the patient's last scheduled visit or last contact, the physical therapist or physical therapist assistant shall document a final summary of the patient's physical therapy status upon discharge from the patient’s current episode of treatment. (2) The discharge summary shall include, but is not limited to: (a) Date and reason for discharge, or self discharge, if known; (b) Degree of goal achievement or reasons for goals not being achieved; (c) Summary of the patient's status at the time of discharge; and (d) Recommendations for follow-up care, if any. (3) A discharge summary is not required when another licensed medical professional documents a patient’s discharge from an acute inpatient care facility as that term is defined in ORS 442.470(1).