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

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. 

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.

• Discharge summary sample for F33.41 Major Depressive Disorder, recurrent, in partial remission diagnosis - adult
• Discharge summary sample for F43.10 Post Traumatic Stress Disorder diagnosis - adult 
• Discharge summary sample for F41.1 Generalized Anxiety Disorder diagnosis - teen

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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