Speech/Language Pathology Discharge Summary

1 Caring for Your Quality of Life SLP Discharge Summary Page 1 of 1 Revised: 03/2012 Speech/Language PathologyDischarge Summary Patient s Last Name First Name MI HICN: Certification Period From: Through: # of Visits (Including Eval) Date of Discharge Summary of Progress (Provide objective measurements that directly relate to the LTGs established in the POT) LTG #1 Met Admission Status: Discharge Status: LTG #2 Met Admission Status: Discharge Status: LTG #3 Met Admission Status: Discharge Status: LTG #4 Met Admission Status: Discharge Status: LTG #5 Met Admission Status: Discharge Status: Reason for Discharge (Check all that apply): The patient has achieved the goals established at admission.

2 The patient has achieved the maximum benefit from skilled intervention. The patient desires not to continue with rehabilitation (Explain): _____ The patient is no longer able to participate in the rehabilitation program. (Explain): _____ Additional Comments: Discharge Recommendations Home Program _____ Medical Follow Up: _____ Referral: _____ Other: _____ Other: _____ Professional Establishing This Discharge Report Therapist s Name & Credentials (Please Print) Therapist s Signature Date _____ X_____ _____