1. Discharge / Transition Plans & Discharge Plans KNR 279 Shank & Coyle, 2002 Stumbo & Peterson, 2004

2. P IN SOAP  Additional information that is needed  Referrals  Specific program (freq. & duration)  New BO  Interventions & facilitation  When to reevaluate

3. DISCHARGE / TRANSITION PLAN  Should begin upon admission  Purpose is to support successful transition to community living or alternative placement Criteria for discharge  Where live after discharge?  What services available there?  What is the ultimate leisure goal?

4. DISCHARGE NOTE (or Discharge Summary)  Final component of client’s record  Provides continuity to tx. plan & summary of services  D/C plan may go to agencies where client is referred  May not be legally required but our professional standards require

5. DISCHARGE NOTE CONTENT  Each agency has own content & format Narrative Standardize forms or checklists SOAP  Use SOAP for class (OAP)

6. DISCHARGE NOTE CONTENT  O Major problems or goals  Related to leisure  Reason for referral to TR  Significant findings from TR assessment TR services received by client  Types, frequency, duration Response to services  Goals achieved  Summary of previous progress notes  No new information

7. DISCHARGE NOTE CONTENT  A Remaining problems on discharge Related to leisure

8. DISCHARGE NOTE CONTENT  P Plan for post D/C leisure involvement Reflects future residence Referrals to agencies Information or materials given to client or family  Handouts  Adaptive equipment  Resource contacts