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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. 

 

 

REFERENCES AND TEST>>