Clinical Reference

Therapy Discharge Summary Template and Example

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Reviewed by the WellNotes Clinical Team

What is a therapy discharge summary?

A therapy discharge summary is the closing document in a client's record. It states the dates and type of services, the reason for treatment, the diagnosis, what was done, progress toward each goal, the client's condition and risk status at discharge, the reason for discharge, and the aftercare plan and referrals.

When do you write a discharge summary?

Write it when an episode of care ends: the client met their goals, chose to stop, stopped attending, moved to another provider or level of care, or the service ended for another reason. Many programs set a deadline after the last contact; check your agency policy and payer contracts.

For psychiatric hospitals, federal Medicare rules are specific. Under 42 CFR 482.61(e), the record of every discharged patient must include a discharge summary with a recapitulation of the hospitalization, recommendations from the appropriate services about follow-up or aftercare, and a brief summary of the patient's condition at discharge. General hospital rules in 42 CFR 482.24 also call for a discharge summary with the outcome of hospitalization, disposition and provisions for follow-up care. Outpatient practices are usually governed by state rules, licensing boards and payers instead, which is why the same core content is a good default everywhere.

Discharge summary template

Keep it to one page when you can. Summarize; do not paste progress notes.

Episode of care

Dates of service
first and last contact dates
Services provided
modality, frequency, number of sessions attended and missed
Reason for referral
presenting problem at intake, briefly
Diagnosis
at intake and at discharge, if changed

Course of treatment

Interventions used
main approaches and any coordination of care
Progress toward goals
each treatment plan goal: met, partly met or not met, with measures at start and end

Status at discharge

Condition at discharge
current symptoms, functioning and most recent measure scores
Risk status
most recent risk screen and result
Reason for discharge
goals met, client choice, no contact, transfer, other

Aftercare

Recommendations
what the client should continue, and warning signs to return
Referrals and coordination
who, and whether records were sent with consent
Crisis resources given
for example 988 and local crisis services
Signature and date
clinician name, credentials, date

Discharge summary examples

All examples are fictional and de-identified. They show structure and level of detail, not clinical advice for a real client.

Example 1: Planned discharge, goals met (adult anxiety)

Adult client in outpatient CBT for generalized anxiety.

Episode of care
Weekly individual CBT, then every two weeks for the last month. 16 sessions attended, 1 cancelled. Referred by primary care for daily worry and insomnia. Diagnosis: generalized anxiety disorder (unchanged).
Course of treatment
Psychoeducation, cognitive restructuring, scheduled worry time, sleep hygiene and stimulus control. Coordinated with primary care with consent. Goal 1 (reduce worry to a manageable level): met, GAD-7 from 16 at intake to 5. Goal 2 (sleep 7 hours most nights): met, client reports 6.5 to 7 hours on 5 or more nights a week. Goal 3 (resume driving to visit family): met.
Status at discharge
Mild residual worry during stressful weeks, managed with skills. Working full time. Denied SI/HI at the last three sessions. Discharged by mutual agreement after goals were met.
Aftercare
Continue daily worry time and the sleep routine. Return if worry interferes with sleep or work for two weeks or more. Primary care to continue medication management. Client given the clinic number and 988 information.

Example 2: Client stopped attending (administrative discharge)

Adult client in treatment for depression who stopped attending without notice.

Episode of care
Weekly individual therapy. 6 sessions attended; no contact for the 6 weeks since the last session. Diagnosis: major depressive disorder, single episode, moderate.
Course of treatment
Behavioral activation and cognitive restructuring. Goal (increase daily activity and reduce depressive symptoms): partly met, PHQ-9 from 19 at intake to 13 at the last session.
Status at discharge
Last seen six weeks ago: mood improved, denied SI/HI, safety plan on file and reviewed. Outreach: phone call and voicemail on two dates and a letter offering to resume services, sent per clinic policy. No response. Discharged for no contact after the outreach period in clinic policy.
Aftercare
The letter included the clinic number, an invitation to return and 988 Lifeline information. Recommended continued treatment and follow-up with primary care for medication.

Example 3: Transfer to a higher level of care (substance use)

Adult client in outpatient counseling referred to an intensive outpatient program.

Episode of care
Weekly outpatient counseling, 8 sessions. Diagnosis: alcohol use disorder, moderate at intake; severity increased during treatment.
Course of treatment
Motivational interviewing and relapse prevention planning. Goal (reduce drinking days to two per week): not met; drinking increased to daily after a relationship ended.
Status at discharge
Daily drinking with morning shakes reported. Denies SI/HI. Agreed that more support is needed. Discharged from outpatient care for transfer to a higher level of care.
Aftercare
Referred to an intensive outpatient program; intake scheduled. With written consent, records sent and warm handoff call completed. Advised to seek medical evaluation before stopping alcohol because of withdrawal symptoms. Crisis resources given, including 988.

What should a discharge summary include?

Whatever the setting, a reader should be able to answer five questions from the summary alone: why the client came, what was done, what changed, how the client was doing at the end, and what should happen next. Tie progress to the goals in the treatment plan, report the same measures you used at intake, and state the risk status from the most recent screen. If the client stopped attending, document your outreach attempts and the resources you offered.

Clinical language for discharge summaries

Use neutral, factual wording for the reason for discharge: "no contact after three outreach attempts" rather than "client dropped out" or "noncompliant." Report progress with numbers where you have them and say plainly when a goal was not met. Write the aftercare plan for the next reader, who may be the client, a new clinician or a payer reviewer.

Keep the summary consistent with the rest of the record. The diagnosis, goals and measures should match the intake and treatment plan, and any change (a new diagnosis, a goal dropped by agreement, a change in level of care) should be explained in a sentence rather than appearing for the first time at discharge. If the client was referred elsewhere, name the service and whether the transfer of records was completed with written consent.

Common discharge summary mistakes

  • Not writing one at all when a client simply stops attending.
  • Copying the last progress note instead of summarizing the whole episode of care.
  • Reporting "progress made" without the measures or goal status that show it.
  • Leaving out the risk status at the last contact.
  • No aftercare plan, referral or crisis information.
  • Judgmental wording about why treatment ended.

Frequently Asked Questions

What is the difference between a discharge summary and a termination note?

Many clinicians use the terms interchangeably. When they differ, a termination note documents the final session itself, while the discharge summary summarizes the whole episode of care from intake to discharge, including progress on goals and the aftercare plan.

Do I need a discharge summary if the client just stopped coming?

In most settings, yes. Close the record with a summary of the treatment provided, the status at the last contact, the outreach you attempted and the resources you offered. Follow your organization's policy for how long to wait and how to reach out.

How long should a therapy discharge summary be?

Usually one page or less for outpatient therapy. Inpatient and residential programs often have longer, structured forms because of their regulatory requirements. Summarize instead of repeating progress notes.

Should the client get a copy of the discharge summary?

Share the aftercare recommendations with the client in a form they can use. Whether and how to provide the full summary depends on the client's request, your organization's policy and the privacy rules that apply to your records.

Sources

This page is educational reference material for clinicians. It does not replace clinical judgment, supervision, or the requirements of your licensing board, payer and organization.

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