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.


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