To prevent liability at discharge, which items should be documented?

• A. Final functional level, recommendations, Home Exercise Program (HEP) provided, and equipment needed.
• B. Patient satisfaction survey.
• C. Date of admission.
• D. Frequency of follow-up visits.

Answer: (A)

Thorough discharge documentation should clearly capture what the patient can do at the end of care, what happens next, and what is needed to continue safely at home. Documenting the final functional level shows objective progress and current abilities, which is essential for accountability and to justify the discharge decision. Including recommendations lays out the plan for ongoing management, so caregivers know what to do after leaving the facility. Providing the Home Exercise Program gives specific, actionable activities the patient should perform, promoting continuity of therapy and reducing the risk of regression. Listing the equipment needed ensures the patient has the necessary tools to carry out the plan and demonstrates that safety and feasibility were considered.

This combination supports a standard of care by showing the patient was educated, given a clear plan, and equipped to follow through, which helps protect against liability if questions arise after discharge. Pieces like a patient satisfaction survey or basic administrative details (such as date of admission) don’t address the post-discharge plan or safety needs. Similarly, noting how often follow-up visits occur is part of care planning but does not by itself document the immediate plan, safety, or equipment required for home use.