A discharge summary is the final piece of clinical documentation in the Golden Thread. It summarizes the whole episode of care and is written when a client is discharged from the provider’s care. When a discharge summary is not completed, the Golden Thread — or clinical narrative for a client’s episode of care — is incomplete. A client can still be considered open, and under the care of the provider, which can present risk and liability concerns.
Use the discharge summary when:
The discharge includes:
When discharging a client who is disengaged from care, you may wish to include details about the number and types of outreach used to re-engage clients and recommendations for next episode of care should the client seek services again.
As a resource for SonderMind providers, we’ve created a discharge template that you can access here.
To help you fill out discharge summaries, we’ve also developed examples featuring fictional clients and their clinical records. The information in each sample is for illustrative purposes only and does not contain real client information.
If you’re not a SonderMind provider, we invite you to join a community of mental health professionals who are dedicated to providing the highest-quality care and changing people’s lives. As part of the SonderMind community, you’ll have access to tools, resources, and support to provide the best care to your clients.
The Golden Thread: Using Medical Record Documentation Templates to Prove Medical Necessity
Initial assessment in the Golden Thread: Intake template
Road map for care in the Golden Thread: Treatment plan template
Documenting therapy sessions in the Golden Thread: Progress note template
**Disclaimer: This document is intended for educational purposes only. Please check with your legal counsel or state licensing board for specific requirements.
SonderMind Inc.© 2022