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Discharge / Transition Plans & Discharge Plans

Discharge / Transition Plans & Discharge Plans. KNR 279 Shank & Coyle, 2002 Stumbo & Peterson, 2004. P IN SOAP . Additional information that is needed Referrals Specific program (freq. & duration) New BO Interventions & facilitation When to reevaluate. DISCHARGE / TRANSITION PLAN.

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Discharge / Transition Plans & Discharge Plans

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  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

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