Discharge Summary
What a discharge summary is in mental health care, what to include, how it differs from a termination note or discharge plan, and a fictional outpatient example.
Quick Answer
A discharge summary is the closing note written when a person leaves a hospital stay, a program or a course of outpatient therapy. It summarizes the reason for treatment, the treatment provided, progress toward goals (ideally with measures), the person’s condition and risk at discharge, the reason for discharge, and the aftercare plan, including referrals and what to do if symptoms return. In US hospitals, the CMS Conditions of Participation require one in every discharged patient’s record. In outpatient therapy it is often called a closing or termination summary.
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Definition
A discharge summary is the record that closes an episode of care. It tells the next clinician, and the person themselves, what happened during treatment and what should happen next. It is written when the person leaves an inpatient unit, residential or partial hospital program, intensive outpatient program, or a course of outpatient therapy.
In US hospitals, the CMS Conditions of Participation require a discharge summary in the record of every discharged patient. For psychiatric hospitals, 42 CFR §482.61(e) asks for a recap of the hospitalization, recommendations for follow-up or aftercare, and a brief summary of the patient’s condition at discharge. Outpatient practices follow state rules, payer contracts and their own policies, which usually expect a closing summary when a case is closed.
Sharing a discharge summary with another provider follows HIPAA, state law and, for some substance use disorder records, 42 CFR Part 2. Many clinicians get the person’s written consent and note who received a copy.
What to include in a discharge summary
| Section | What to include |
|---|---|
| Identifying information and dates | Name, record number, dates of admission or first session and discharge, number of sessions or length of stay, treating clinician |
| Reason for treatment | Presenting problem or reason for admission, and referral source |
| Diagnoses | Working diagnoses at start and at discharge, with ICD-10-CM codes where used |
| Treatment provided | Type and frequency of therapy, approaches used (for example CBT), groups, coordination with prescribers or other services |
| Progress toward goals | Each treatment-plan goal and whether it was met, partly met or not met, with measure scores at start and end where available |
| Condition and risk at discharge | Current symptoms, functioning, mental status, and a current risk assessment for suicide, self-harm and harm to others |
| Reason for discharge | Goals met, mutual agreement, client choice, transfer, moved away, or no contact after outreach attempts (with dates) |
| Aftercare and referrals | Follow-up appointments, referrals, medication follow-up with the prescriber, relapse warning signs, how to return to care, crisis resources |
Discharge summary vs discharge plan vs termination note. A discharge plan is made during treatment and sets out what needs to be in place before and after discharge. The discharge summary is written at the end and records what happened. In outpatient therapy, a termination note often documents the final session itself; the closing or discharge summary covers the whole course of care. Some practices combine the two.
How to write a discharge summary: fictional outpatient example
Keep it factual and short enough that the next clinician can read it in a few minutes. Use measures where you have them, and make the aftercare plan specific.
Weak documentation: “Client completed treatment and is doing well. Discharged.”
Stronger documentation: “Discharged by mutual agreement after 14 sessions; both treatment goals met. GAD-7 16 at intake, 6 at final session. Driving on the highway again three times a week. Relapse warning signs and return-to-care steps reviewed.”
Reason for treatment: Fictional adult client, 29, self-referred 5 months ago for worry and panic attacks that had stopped her driving on highways. Working diagnosis: generalized anxiety disorder (F41.1); panic attacks without panic disorder.
Treatment provided: 14 sessions of individual CBT over 5 months: psychoeducation, cognitive restructuring, worry scheduling, graded exposure to highway driving. Medication managed by her primary care physician throughout; with client’s consent, therapist sent a progress update at session 8.
Progress toward goals: Goal 1 (reduce worry to a level that does not disrupt work): met by client report. GAD-7 decreased from 16 at intake to 6 at the final session. At discharge, she reports completing her usual duties and meeting deadlines without worry interrupting work over the past four weeks. Goal 2 (drive on highways without avoidance): met. Now drives on the highway to work three times a week; last panic attack 7 weeks ago.
Condition at discharge: Mood “good.” Affect full range and congruent. Thought process linear. Reports mild worry before work deadlines that she manages with skills learned in treatment. At the final session, denied suicidal thoughts, self-harm and thoughts of harming others on direct questioning; no history of suicide attempts or self-harm during treatment.
Reason for discharge: Treatment goals met; discharge agreed with client at session 12 and sessions tapered to every two weeks.
Aftercare: Continues medication follow-up with her primary care physician; client agreed to a copy of this summary being sent there. Written relapse-prevention plan given: warning signs (avoiding highway driving again, worry most days for two weeks or more), skills to restart, and how to request a return appointment, which she can do at any time. Client knows to call or text 988 in a crisis, or call 911 or go to the nearest emergency department in an emergency.
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Tips for writing a discharge summary
Write it soon after discharge: Details fade quickly. Many organizations set a deadline; check your policy and payer requirements.
Report each goal: Say whether each treatment-plan goal was met, partly met or not met, with evidence.
Use measures: Start and end scores on the same tool, such as the PHQ-9 or GAD-7, show change more clearly than words alone.
Record current risk: Document a risk assessment at discharge, not just at intake, and the crisis resources the person was given.
Make aftercare specific: Name the referral, the appointment if booked, the warning signs and how to return to care.
Document unplanned discharges: If the person stopped attending, record outreach attempts and dates, any risk concerns and the closing letter sent.
Common mistakes to avoid
- “Doing well, discharged”: with no goals, measures or condition at discharge, the next clinician learns nothing
- No risk assessment at discharge: risk can change during treatment; record the current picture
- Vague aftercare: “follow up as needed” does not say with whom or when
- Copying the intake: the summary should show what changed, not repeat the starting picture
- Sharing without checking consent rules: confirm HIPAA, state law and 42 CFR Part 2 requirements before sending a copy
Frequently asked questions
What is a discharge summary in mental health?
A discharge summary is the note written when a person leaves a hospital stay, program or course of therapy. It records why they came, the treatment provided, progress toward goals, their condition and risk at discharge, the reason for discharge and the aftercare plan.
What should be included in a discharge summary?
Dates of treatment, reason for treatment, diagnoses, treatment provided, progress on each treatment-plan goal (with measure scores if available), condition and current risk at discharge, the reason for discharge, and aftercare: referrals, follow-up appointments, warning signs, how to return and crisis resources.
What is the difference between a discharge summary and a termination note?
A termination note usually documents the final therapy session itself. A discharge summary covers the whole episode of care from start to finish. Some outpatient practices use one closing summary for both; check your organization’s policy.
Is a discharge summary required?
In US hospitals, yes: the CMS Conditions of Participation require a discharge summary in each discharged patient’s record, and 42 CFR §482.61(e) sets what psychiatric hospitals must include. For outpatient practices, requirements come from state rules, payer contracts and organizational policy, which commonly expect a closing summary.
How do you write a discharge summary when a client stops attending?
Record the last session date, your outreach attempts with dates and methods, any risk concerns at last contact and how you addressed them, the closing letter or message sent, and how the person can return to care. State that discharge was due to no contact after outreach.
Related guides: discharge summary template · treatment plan · outcome measures · risk assessment · progress notes.
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Further Reading
- 42 CFR Part 482 (eCFR) — The CMS Conditions of Participation for hospitals, including the discharge summary requirements in §482.24(c) and, for psychiatric hospitals, §482.61(e).
- Discharge summary template — A section-by-section template you can adapt for outpatient or program discharges.
- NIMH (National Institute of Mental Health) — Plain-language information on mental health conditions, their symptoms and current research.