ERK4499 - SECTION 14: THE DISCHARGE SUMMARY
Section 14: The Discharge Summary
The discharge summary is usually the final part of the clinical record to be completed, marking the transition from an active case to a closed case. Whenever possible, a joint determination should be made by both the clinician and the client that the client is agreeing to terminate services and the case is to be closed. If a client has dropped out of treatment without notifying the clinician, attempts should be made to follow up with the client to verify the case status. That attempt – and any communications concerning that attempt – should be recorded on a Case Activity Record.
In reality, it is often not possible to communicate with clients after they have elected to drop out of treatment. This can make it difficult to know how long to wait before a case is closed and a discharge summary is created. There is no set formula for this question, but unless a termination process has been completed and a discharge date determined in a joint process with a client, it is sensible to wait for several months before closing a case.
In writing a discharge summary, there are several items that should be included:
- Treatment goals that were accomplished
-Treatment goals that were left uncompleted
- The last known disposition of the case
- Any follow-up plans that were made, additional services recommended and referrals made
- A case summary and any comments necessary to understand the closing of the case
A template for a discharge summary is shown below.
Pat R. Clinician, LCSW
Discharge Summary
Client Name:_________________________ Date/Time: ____________________
Treatment Goals Accomplished:
__________________________________________________________________________________________________________________________________________________________________________________
Treatment Goals Not Completed:
__________________________________________________________________________________________________________________________________________________________________________________
Case Disposition:
__________________________________________________________________________________________________________________________________________________________________________________
Follow-up Plans/Additional Services Recommended:
__________________________________________________________________________________________________________________________________________________________________________________
Referrals Made:
Referral:_________________________ Phone: ____________________
Referral:_________________________ Phone: ____________________
Rationale for Referral :
__________________________________________________________________________________________________________________________________________________________________________________
Comments/Case Summary:
__________________________________________________________________________________________________________________________________________________________________________________
Pat R. Clinician, LCSW:_________________________ Date:_______________
This completes the course material. A link to the post-test may be found at the bottom of the references page in the next section.