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Compliance and documentation

How to have a successful client discharge (with summary template)

An abstract illustration that depicts an arrow pointing to the natural endpoint to therapy.

Every discharge situation is different, but a few best practices can help ensure the transition and 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 document the discharge. 

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, and the most important steps you should consider when you’re discharging a therapy client.

Knowing when to end your relationship with a client

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.

How to document a discharge summary

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.

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. 

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:

  • If you’ve completed your treatment goals, your discharge summary can help document the completion and provide follow-up recommendations.
  • If a client relocates or leaves the area, a discharge summary helps ensure their treatment information is properly documented for continuity of care, facilitating a smooth transition to new providers in their new location.
  • If a therapist is leaving their position, discharge summaries help ensure the client can make a smooth transition to another provider by detailing the client's treatment history and ongoing care needs.
  • If a client needs to be referred to a new level of care (e.g., from outpatient to inpatient, or to a specialized facility), the discharge summary helps to communicate the treatment history, reason for referral, and any relevant information for the new care team.
  • The provider is unable to contact or locate the client despite multiple attempts to contact them, a discharge summary provides a record of the provider's efforts to reconnect and outlines any concerns or recommendations.


Why a discharge summary is important

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:

  • Continuity of care: A discharge summary ensures that the next care provider has a clear understanding of the client's history, treatment outcomes, and ongoing needs. This promotes continuity of care, minimizing the risk of errors or miscommunication when the client transitions to another provider or facility.
  • Documentation of services: The discharge summary serves as a formal record of the services provided to the client. This documentation is crucial for legal compliance, insurance billing, and auditing purposes. By having a detailed account of the treatment course, providers can demonstrate that appropriate care was delivered.
  • Legal protection: A well-prepared discharge summary provides legal protection to the mental health provider. It serves as evidence that the provider followed proper protocols and made informed decisions. In the event of legal disputes or inquiries, this document can be instrumental in establishing that the provider met professional standards and indicates when the client was no longer under the provider’s care.
  • Clarity for the client and family: A detailed discharge summary provides clarity to clients and their families about the treatment process and next steps. It includes recommendations for follow-up care, which helps ensure compliance and reduces confusion about the client's ongoing care plan.

Tips for a successful therapy termination

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. 

1. Talk about wins

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. 

2. Create a self-care plan 

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. 

3. Create a plan for your relationship, too

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). 

4. Be honest 

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. 

5. Help bridge the gap

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.

Discharge summary example

As with your client’s progress notes, your discharge summary should include certain information that sums up your work together, such as: 

  • Client information 
  • Diagnosis — both their initial diagnosis and their diagnosis at the time of discharge
  • Current symptoms
  • Discharge date
  • Services provided
  • Treatment summary
  • Progress toward goals
  • Reason for discharge
  • Post discharge plan, including continuing care recommendations.

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:

  • Jane presented with symptoms of generalized anxiety, including excessive worry, difficulty relaxing, and physical tension.
  • She also reported symptoms of depression, such as low mood, feelings of hopelessness, and loss of interest in activities.


Diagnosis:

  • Primary Diagnosis: Generalized Anxiety Disorder (F41.1)
  • Secondary Diagnosis: Major Depressive Disorder, Single Episode (F32.1)


Treatment Plan and Interventions:

Therapeutic Approach: Cognitive Behavioral Therapy (CBT)


Treatment Goals:

  1. Reduce symptoms of anxiety and depression.
  2. Increase coping skills to manage stress and negative emotions.
  3. Improve self-esteem and self-confidence.


Interventions:

  • Cognitive restructuring to challenge negative thought patterns.
  • Relaxation techniques, including deep breathing and progressive muscle relaxation.
  • Behavioral activation to increase engagement in pleasurable activities.


Progress and Achievements:

  • Jane demonstrated significant improvement in her anxiety symptoms, reporting decreased worry and tension.
  • She developed effective coping strategies to manage stressors and regulate her emotions.
  • Jane gained insight into the connection between her thoughts, feelings, and behaviors, leading to more adaptive responses to challenges.


Challenges and Setbacks:

  • Jane experienced setbacks related to job search stressors, but she was able to utilize coping skills to navigate these challenges effectively.


Collateral Involvement:

  • Jane's spouse, John, was involved in a few sessions to provide support and gain understanding of Jane's experiences.


Recommendations and Follow-up:

  • Jane is encouraged to continue practicing the skills learned in therapy to maintain progress.
  • Referral to a career counselor for additional support with job search and career planning.
  • Suggested participation in a support group for individuals coping with job loss and mental health concerns.


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

Headway is a free service that makes it easier and more profitable for therapists and psychiatrists to accept insurance.

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