What should I include on a discharge note in regard to pulmonary rehabilitation and tobacco services?
Evidence of instruction on a home exercise program, as needed, and any plans for further exercise or therapy should be documented:
- Reason for discharge
- Patient’s condition at discharge
- Final summary of patient’s progress toward goals as specified in the treatment plan
- If goals are not met, why?
- Physician approval of discharge with follow-up documentation on patient improvement and progress toward proposed goals for discharge, or lack thereof with referral to other services.
This question was answered in our Coding Essentials for RT/Pulmonary Function. For more hot topics relating to respiratory services, please visit our store or call us at 1.800.252.1578, ext. 2.