Discharge from Active Treatment

Discharging Your Patient from Active Treatment

Given treatment success, the medical necessity of treatment for your patient will come to an end. As a provider, you must proficiently define and document the conclusion of medical necessity with efficient documentation of a discharge report ending the episode of active care.

Documenting a Patient’s Discharge from Active Treatment

Your discharge summary report is often straightforward offering one of four scenarios:

1. The patient responded well and met all treatment goals
2. The patient improved but maintains residual symptomology
3. The patient did not respond positively and is referred to another healthcare professional OR

The patient dismissed themselves from care prior to completion of the recommended care.

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