Therapy discharge plan

A therapy discharge summary is the end of a special type of relationship. As in all relationships, there is a beginning, a middle, and an end. The intake represents the beginning. The bulk of therapy is the middle and discharge is the conclusion. Some therapists may minimize the importance of discharge plans but they are an essential part of the therapeutic process. Here is why discharge planning deserves your attention.

Why is it important to have a therapy discharge summary?

A therapy discharge summary serves multiple purposes:

• Summarizes goals and progress: One of the main objectives of a therapy discharge summary is to recap the course of therapy. Whoever reads the therapy discharge summary will know what the client was working on and what progress was made. This helps inform the client on their continuing journey and lets other professionals know what has been covered. Plus, the therapy discharge summary acts as another layer of protection for potential legal or insurance problems.

• Facilitates transition: Another priority of a therapy discharge summary is to guide the transition to the client’s next phase of life, whether that is continued treatment with another provider or helping them make decisions once they are on their own. Ideally, after reading the therapy discharge summary, the client will know the steps they need to take to ensure their mental health post-therapy.

• Prevents relapse: An additional goal of a therapy discharge summary is to prevent clients from having the problems that brought them to treatment in the first place. This may involve averting relapse for a specific addiction or avoiding habits that led them down a path toward undesirable emotions and behavior. In any case, the therapy discharge summary will point the client toward the resources and support network they hope will keep the client on track toward a healthy lifestyle.

• Demonstrates an appropriate ending to the therapeutic relationship: As mentioned earlier, therapy is a relationship. And the discharge process is an appropriate way to resolve the therapeutic relationship. It provides the client with critical information for their continued well-being as well as a sense of closure. It also acts as a model of how to manage other endings in the client’s life. Unfortunately, a client may simply terminate the therapy relationship without warning. In those cases, the therapy discharge summary acknowledges the conclusion in a documented format. And it is never a bad idea to have written evidence that supports your work.

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What should a therapy discharge summary include?

A therapy discharge summary can be extraordinarily different depending on your work setting. If you work in a large institution, such as a hospital or residential facility, you can expect a highly comprehensive document that covers almost every aspect of treatment and post-treatment recommendations. In contrast, the therapy discharge summary for outpatient therapists runs the gamut, from creating formal discharge plans to recording the end of therapy with a simple letter or progress note.

Basic components of a discharge plan

• Demographic information: This will include an abridged version of what is contained in the intake paperwork. You want it to stand on its own but it shouldn’t be entirely repetitive. Stick to the basics, such as name, address, date of birth, marital status, race, sexual orientation, and gender identity. Also, include the date of intake and discharge.

• Presenting problem: The presenting problem is why the client sought therapy in the first place. It is important to note that it may be different from the main issues that were discussed in therapy. For example, a client may come to therapy for a problem with their partner and end up taking more time addressing their problematic family dynamics during childhood.

• Treatment goals and summary of progress: This part of the discharge plan discusses the bulk of therapy. What were the goals the client worked towards? Did they achieve their objectives? It would be appropriate to talk about strengths and coping strategies developed during therapy. You can also include your therapeutic approach in this section. For example, what type of counseling techniques did you use, and were they successful? Basically, what worked and what didn’t? Finally, what was the reason for termination?

• Recommendations: These are strategies for maintaining progress and preventing relapse. They may include self-care instructions, community resources for continued growth, how to involve their support system, and specific referrals. Challenges to successful implementation should be included. For instance, what are the complexities of the client’s condition that could hinder a smooth transition? Or, what might prevent recommendations from being followed?

• Diagnostic information: Was there a diagnosis? If not, what were your clinical impressions?

• Follow-up: Follow-up is customary when you are discharged from an inpatient institution. This frequently includes future appointments with another professional, such as a medication provider or outpatient therapist. You can also set a time to make contact with the client to check up on how they are doing and see if they are following through with their discharge recommendations. This is especially important for clients who may be prone to emotional instability. Follow-up is something that is much more rarely implemented in outpatient therapy. Nevertheless, it is a practice to which to aspire, no matter what your therapy setting.

Therapy discharge summary example

While therapy discharge summaries vary on setting, location and a number of other factors, below is a therapy discharge summary example. 

• Date of service
• Termination date
• Start date for this episode of care
• Client name
• Medical record number
• Session seen this episode of care
• Type of treatment (ie., Individual, couples, family, group, collateral/parenting)
• Service provided (ie., include the appropriate CPT code/s here such as 9079 for psychological evaluation or 96101 for psychological testing.)
• Presenting problem
• Treatment goals and summary of progress
• Recommendations
• Diagnostic information
• Follow-up
• Clinician name
• Date

Additionally, the following are a variety of therapy discharge summary examples for different types of clients in diverse settings:

• This is an example of a comprehensive discharge plan for a suicidal client that you would likely find as part of an inpatient termination.

• An outpatient discharge summary for a teenager suffering from generalized anxiety.

• This link includes two termination letters that might commonly be used as part of outpatient therapy. One is a letter that serves as a discharge notification for therapy that did not work out and the other notes the successful completion of therapy.

•  The American Psychological Association has very concise discharge templates for therapists in every state.