Documenting end of care in the Golden Thread: Discharge summary template

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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.

When should I use the discharge summary?

Use the discharge summary when:

  • Your client completes and/or successfully ends care
  • Your client disengages from care and you need to document closure of the episode of care
  • The client is no longer considered your active client

What is in the discharge summary?

The discharge includes:

  • Diagnosis at discharge
  • Detailed reasons for reasons for discharge (including progress toward treatment goals)
  • Any risk factors at the time care ended
  • Referrals and resources of benefit to the client

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.

How can I get the discharge summary template?

As a resource for SonderMind providers, we’ve created a discharge template that you can access here

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.
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You might also want to read

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

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**Disclaimer: This document is intended for educational purposes only. Please check with your legal counsel or state licensing board for specific requirements.

SonderMind Inc.© 2021

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