How to use the ADNM-8 assessment for adjustment disorder
Learn more about the ADNM-8 assessment and how you can incorporate it into your practice.
Every discharge situation is different, but a few best practices can help ensure the discharge note documentation process is successful.
As rewarding as therapy can be for both you and the people you work with, eventually, all therapeutic relationships come to an end. It’s your role as a therapist to know when to discharge a client, to help your client navigate their steps forward, and to formally create the discharge note.
Every discharge situation is different, but a few best practices can help ensure the transition and documentation process is successful. Keep reading to learn when it may be time to help your client move on, how to document the end of therapy, what a discharge summary example looks like, and the most important steps you should consider when you’re discharging a therapy client.
A discharge summary, also called a discharge note, is a comprehensive document that summarizes a client's treatment and status at the time of discharge from care. It includes information about the client's diagnosis, the treatment they received, their progress during care, and any recommendations for ongoing treatment or follow-up.
When you start therapy with a new client, you should ultimately have the end in sight. Your discharge conversations will feel more natural and less jarring if you set expectations with your client early.
“Discharge planning starts at the beginning,” says Abby Gagerman, a Chicago-based private practice therapist. “You always want to define therapeutic goals early on, which includes what ‘better’ looks like.”
The best-case scenario is ending therapy because your client has met their goals and they’re ready to move on. But sometimes, the end of your relationship is forced: Maybe your client is using a new insurance plan you’re not credentialed with. Perhaps the client no-shows or just wants to end therapy. Other times, Gagerman says, a person might develop a condition you don’t treat or need a higher level of care, like an intensive outpatient program or partial hospitalization.
Either way, it’s a good idea to be prepared for ending therapy well — both for your sake, and the well-being of a client you’re not going to continue treating.
You’ll want to note that your client is discharging in two places: the progress note after the client’s final session, as well as in a formal discharge summary documented to the client’s chart.
The discharge summary documentation process is a valuable way to reflect on your work with the client, including what went well and what you could have done better. Your documentation also serves as a vital communication tool, ensuring that critical information about the client's care is recorded and can be shared with other healthcare providers.
It should be written as close to the time of discharge as possible to ensure that it accurately reflects the client's status and the outcomes of treatment:
Writing a discharge summary benefits both the client and the mental health provider. Here are some reasons why every provider should provide a discharge summary at the end of their relationship with a client:
Because all of your client cases are different, the grounds of your discharge — and the steps you follow — will be unique, too. Following these steps can help keep the process smooth for both you and your client.
Ideally, you’ll see your client for one or two final sessions before discharging them. During this time, Gagerman recommends taking time to reflect on the time you’ve spent together. Review their goals and progress so your client feels empowered about continuing their mental health journey going forward.
While you won’t be seeing your client for therapy post-discharge, you should still take time to help them create a mental health plan to implement after they stop seeing you.
“Along with helping them see their progress, you want to come up with next steps, whether that’s working with a specialist or keeping up with a self-care regime,” says Gagerman. “You don’t want to end and just say ‘good luck.’”
You may also decide to send them off with a plan for coming back to therapy when they’re ready.
When you end therapy, be sure to explicitly define the boundaries of your relationship going forward.
“You’ll want to decide whether the client will be allowed to contact you and come back for booster sessions if needed,” says Gagerman.
If your practice is full, let your client know ahead of time that while you can’t treat them again in the immediate future, you can help them find a new provider. If you’re open to fitting them in on an as-needed basis, create a game-plan (and perhaps let the client know they may have to wait a week or two for an opening).
And if someone is moving or going to a new therapist who specializes in something you don’t treat, be clear you can’t treat them and pinpoint a communication plan you both feel comfortable with (for example, whether you’re OK with email updates or if it’s better to end communication).
No matter the terms of the discharge, it can be hard for both the client and therapist to end their therapeutic relationship. Take time to share the positive parts of your work together in the last session.
“One of the most healing parts of therapy is the relationship itself,” says Gagerman. “You can remind your client that even when they showed you their worst, you still cared about them.”
If you think it’s appropriate, you can also share a token of their growth, such as a printed-out quote that represents your work together.
If your client is moving out of state or moving on to a therapist who treats something you don’t, do your best to help bridge the gap. That could include helping your client find a new provider, having a phone conversation with them, and/or filling out all the necessary paperwork — such as release of information documents — to ensure a smooth transition.
“The client can start their therapy work from a much stronger place if you help with some of that bridge work,” says Gagerman.
As with your client’s progress notes, your discharge summary should include certain information that sums up your work together, such as:
Here’s how that may look in a discharge summary example:
Provider information:
Tanya Therapist, LPC
February 12, 2024
Patient Information:
Name: Jane Doe
Date of Birth: 01/01/1990
Address: 123 Main Street, Anytown, USA
Phone Number: (555) 555-5555
Emergency Contact: John Doe (Spouse) - (555) 123-4567
Referral Information:
Referring Provider: Dr. Sarah Smith
Reason for Referral: Jane was referred for therapy to address symptoms of anxiety and depression following a recent job loss.
Presenting Issues:
Diagnosis:
Treatment Plan and Interventions:
Therapeutic Approach: Cognitive Behavioral Therapy (CBT)
Treatment Goals:
Interventions:
Progress and Achievements:
Challenges and Setbacks:
Collateral Involvement:
Recommendations and Follow-up:
Summary:
Jane made significant progress in therapy, demonstrating improvement in symptoms of anxiety and depression. She acquired valuable skills to manage stress and regulate her emotions. Although challenges arose during the therapeutic process, Jane displayed resilience and commitment to her treatment goals.
Termination:
The therapeutic relationship with Jane is being terminated after 12 sessions. This decision was made collaboratively, as Jane has achieved her treatment goals and feels confident in maintaining progress independently. We discussed the option of returning to therapy in the future if needed, and Jane expressed readiness to pursue additional support if necessary.
Signature:
Tanya Therapist, LPC
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