When a therapist—whether a full-time employee or a traveling clinician—leaves a practice, it’s not uncommon to discover unfinished documentation, such as a missing discharge report. One of the most frequently asked questions in this scenario is whether another therapist who never treated the patient can write the discharge report based solely on the existing notes in the medical record. Technically, the answer is yes—another licensed therapist could write the discharge summary. However, the real question is: should they?
Any therapist who signs their name and credentials on a discharge report becomes part of that patient’s case, regardless of whether they ever interacted with the patient directly. This can present several concerns. If an insurance company requests the records, or if the patient has an active workers’ compensation claim, pending lawsuit, or any other legal matter related to their care, the therapist who authored and signed that report could be pulled into the case. Without firsthand knowledge of the patient’s condition, progress, and outcomes, the substitute therapist may be at a disadvantage in justifying the clinical decisions or summarizing the treatment provided. While it’s permissible for a different therapist to write the discharge report based on existing documentation, it’s important to weigh the potential risks. Ideally, the therapist who evaluated and treated the patient should complete the discharge report. If that’s not possible, practices should implement a clear policy and ensure thorough internal documentation to protect both clinicians and the integrity of patient care.
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