The letter you send when an episode of care ends, to the patient, their GP or whoever referred them. It records what the problem was, what you did, where the patient ended up, and what should happen next.
It is for any allied health clinician in private practice. A good discharge letter closes the record properly and gives the next clinician a usable summary instead of a request for your notes.
The UK standards it rests on
HCPC Standards of conduct, performance and ethics
Covers keeping accurate records and communicating appropriately with colleagues and other professionals involved in a person's care.
CSP record keeping guidance
The Chartered Society of Physiotherapy's guidance on what a complete physiotherapy record looks like, including the end of an episode.
Professional Record Standards Body (PRSB) standards
UK standards for the headings used in clinical documents such as discharge summaries. Written mainly for the NHS, but a useful reference for structure.
UK GDPR and the common law duty of confidentiality
Sharing a letter with a GP or referrer means sharing health data. Agree with the patient who receives a copy, and record that agreement.
Must include
Patient identifiers: name, date of birth, and NHS number if you hold it
The recipient has to match the letter to the right record without guessing.
Dates of the episode and number of sessions
Gives the reader the scale of the intervention at a glance.
Presenting problem and working diagnosis
What you were treating, in terms another clinician can act on.
Treatment provided
Lets the next clinician avoid repeating what has been tried.
Outcome, ideally with a measure
A before-and-after score (pain, function or a validated outcome measure) says more than "improved".
Reason for discharge and advice going forward
Goals met, plateaued, self-discharged or referred on. Include the home programme and what to do if symptoms return.
Your name, profession, registration number and contact details
Identifies the author as a registered professional and gives the reader someone to ask.
Optional
Recommendations for the GP or referrer
Only where there is something specific to act on, such as an onward referral or imaging.
Red flags to watch for
Useful when the patient is discharged with residual symptoms.
Open-access return period
If you let discharged patients self-refer back within a set time, say so.
Copy list
Shows who else received the letter, so nobody assumes someone else was told.
The template
Replace anything in [square brackets]. Print it, save it as a PDF from the print dialog, or copy the text into your own document.
Name: [Patient name] Date of birth: [DD/MM/YYYY] NHS number: [if held]
Address: [Patient address]
Episode of care
Referred by: [Self / GP / insurer / consultant]
Seen from [first appointment date] to [last appointment date], [number] sessions.
Presenting problem: [Brief description]
Working diagnosis: [Diagnosis or clinical impression]
Treatment provided
[e.g. graded exercise programme, manual therapy, education on load management]
Outcome
[Outcome measure, e.g. PSFS]: [initial score] at assessment, [final score] at discharge.
[Summary of functional change, e.g. returned to running 5 km without pain]
Reason for discharge
[Goals achieved / plateau reached / patient choice / referred on to ...]
Advice and plan
[Home exercise programme and how long to continue it]
If symptoms return: [e.g. contact us within 3 months to be seen without a new referral, or see your GP]
Recommendations for GP or referrer (if any): [Recommendation]
Signed
[Clinician name], [Profession]
[Regulator] registration number: [Number]
Copy to: [Patient / GP / referrer]
Use it in Atlacare
Atlacare does not generate letters. Paste this template into a clinical note to write the discharge summary on the record, mark the patient's treatment plan as Completed, and use the Discharged status on the recall list so they drop out of follow-up. You can also upload the signed letter to the patient's files.
Atlacare