Discharge Summary Template for Therapists
A discharge summary closes an episode of care. It records why the client came, what treatment was provided, how the client changed against the treatment plan goals, their status and risk at discharge, why treatment ended, and the aftercare plan. Below is a copy-ready template, a fictional completed example, wording for the common discharge reasons, and the elements of a hospital discharge summary.
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General documentation guidance, not legal or billing advice. Record-keeping, termination and abandonment rules vary by state, licence board and payer; check yours. All examples are fictional.
Quick answer
- Course of treatment: first and last session dates, number of sessions, modality and frequency.
- Why the client came and what was found: presenting problem and diagnosis at intake and at discharge (if one was made).
- Outcome: each treatment plan goal marked met, partly met or not met, with the evidence (measure scores, client report, observed change).
- Status at discharge: current symptoms, functioning and a current risk assessment.
- Reason for discharge and aftercare: why treatment ended, referrals, relapse-prevention plan, crisis resources (988 in the US), and how to return.
Discharge summary template
Copy these headings into your EHR or note template. Write in plain, factual language; the summary is often the only page a future clinician reads.
| Section | What to write |
|---|---|
| Client and episode | Client identifier per your record system, clinician, first session date, last session date, number of sessions attended (and missed, if relevant) |
| Reason for referral | Who referred the client and the presenting problem at intake, in one or two sentences |
| Diagnosis | Diagnosis at intake and at discharge if one was made, with any change (for example in remission) |
| Treatment provided | Modality (for example CBT, EMDR, family therapy), frequency, any group or adjunct services, coordination with a prescriber or other providers (with authorization where required) |
| Progress on goals | Each treatment plan goal: met, partly met or not met, with the evidence. Include baseline and final scores on the same measure |
| Status at discharge | Current symptoms and functioning, medication status if known, and a current risk assessment (suicidal and homicidal ideation, self-harm, protective factors) |
| Reason for discharge | Goals met, mutual agreement, client chose to end, referral to another level of care or provider, client moved, or no response to outreach |
| Aftercare and referrals | Relapse-prevention or maintenance plan, referrals made, follow-up with the prescriber or primary care, community supports |
| Crisis plan | Crisis resources given (988 in the US, local emergency services) and the warning signs to act on |
| Return to care | Whether and how the client can come back |
| Clinician | Name, credentials, signature and date |
Fictional example: completed discharge summary
Fictional example. Not a real client.
Episode: First session March 3, last session July 14; 16 sessions attended, 1 cancelled.
Reason for referral: Referred by primary care for panic attacks and avoidance of driving after a car accident.
Diagnosis: Panic disorder at intake. At discharge, panic disorder in full remission per clinician assessment.
Treatment provided: Weekly individual CBT with interoceptive and in vivo exposure. Coordinated with primary care at intake and discharge with the client's written authorization.
Progress on goals: Goal 1, reduce panic attacks from about 4 a week to fewer than 1 a month: met (none in the last 8 weeks per panic log). Goal 2, drive on the highway alone: met (drives to work 3 days a week). Goal 3, return to the gym: partly met (attends about once a week). PDSS 17 at intake, 4 at discharge.
Status at discharge: Reports occasional mild anxiety before long drives, managed with the coping plan. At the final session, asked directly about current suicidal thoughts, plan and intent, self-harm and thoughts of harming others: denies each. Asked about past attempts and self-injury: denies. Asked about access to firearms: reports none; medication access and safe storage discussed. Identifies partner and future work plans as reasons for living. Clinician assesses low acute suicide risk based on these findings, improved functioning and engagement in follow-up; risk may change. Crisis response and return-to-care arrangements reviewed.
Reason for discharge: Goals 1 and 2 met; discharged by mutual agreement.
Aftercare: Written relapse-prevention plan reviewed and copy given to client. Continue with primary care. Crisis resources, including 988, reviewed.
Return to care: Client may schedule booster sessions at any time.
The summary gives dates and counts, ties each goal to evidence, records the clinician's risk formulation and its basis, and states the reason for discharge and the aftercare plan. The risk details above belong to this fictional example: document only what you actually asked, assessed and discussed. If the client cannot be reached, record the last assessment date and last known findings, and state that current risk could not be assessed. Goals and objectives usually come straight from the treatment plan template; for measurable goal wording, see treatment plan goals and objectives examples.
Wording for common discharge reasons
| Reason | Example wording |
|---|---|
| Goals met | "Treatment goals 1 to 3 met as described above. Discharged by mutual agreement. Client may return as needed." |
| Client chose to end | "Client chose to end treatment after session 6, citing schedule changes. Progress to date and referrals discussed in the final session." |
| Referral to another level of care | "Referred to an intensive outpatient program for increased support. Records sent with the client's written authorization. Episode closed on transfer." |
| No response to outreach | "Last attended session on May 2. Outreach by phone on May 9 and by letter on May 16 with referrals and crisis resources; no response. Case closed. Client may return at any time." |
| Client moved | "Client relocated out of state. Referral list for the new area provided. Discharged." |
Before closing a case for non-attendance, follow your practice's outreach policy and your licence board's rules on ending treatment, so the client is not left without referrals or crisis resources.
Hospital and medical discharge summaries
Inpatient and medical discharge summaries follow facility rules. For hospitals in the Medicare program, the Conditions of Participation require a discharge summary with the outcome of hospitalization, disposition, and provisions for follow-up care (42 CFR 482.24(c)(4)(vii)). Typical hospital templates also include:
- Admission and discharge dates, admitting and discharge diagnoses
- Reason for admission and significant findings
- Procedures and treatment provided, and the hospital course
- Condition at discharge and disposition (home, skilled nursing, another facility)
- Discharge medications after reconciliation, with changes from admission
- Instructions given to the patient and caregivers, pending results, and follow-up appointments
For outpatient medical visits, MentalNote drafts Medical SOAP notes; see the medical SOAP note generator.
How MentalNote fits
MentalNote does not have a dedicated discharge summary format. It drafts the session notes a good discharge summary is built from, in DAP, BIRP, SOAP, Progress and other formats, from a recorded session (with your client's consent) or, in the Word add-in, from a summary you type. You can also describe your own structure with custom instructions. You review every draft before it goes in the record. See the AI progress notes for therapists and, at the start of care, the intake assessment template.
MentalNote is HIPAA-compliant, with a BAA included on every plan. The free plan includes 5 web-app scribe sessions a month with no credit card; Premium is $99/month or $990/year (pricing).
Discharge summaries: common questions
What should a therapy discharge summary include?
Dates of the first and last session and the number of sessions, the reason for referral and presenting problem, diagnosis at intake and at discharge if one was made, the treatment provided, progress on each treatment plan goal with measure scores where you have them, the client's status and risk at discharge, the reason for discharge, the aftercare plan and referrals, and how the client can return or get help in a crisis.
When should a discharge summary be written?
At the end of the episode of care: when goals are met, when you and the client agree to end, when the client is referred elsewhere, or when the client stops attending and does not respond to your outreach. Your practice policy, licence board or payer may set a deadline after the last contact; follow it.
What is the difference between a discharge summary and a termination letter?
The discharge summary is the clinical record of the whole episode and stays in the chart. A termination or closing letter is sent to the client, often when they have stopped attending, to say the case is being closed, give referrals and crisis resources, and explain how to come back. Keep a copy of the letter in the record and mention it in the discharge summary.
How do I write a discharge summary when the client stopped coming?
Record the last session date, your outreach attempts (dates and method), that the client did not respond or chose not to continue, their last known status and risk, the referrals and crisis resources you sent, and that the case is closed and the client may return. Avoid blaming language; state the facts.
What goes in a hospital discharge summary?
For hospitals, the Medicare Conditions of Participation require the medical record to contain a discharge summary with the outcome of hospitalization, disposition, and provisions for follow-up care (42 CFR 482.24(c)(4)(vii)). Most hospital templates also cover the reason for admission, significant findings, procedures and treatment, condition at discharge, discharge medications after reconciliation, and the instructions given to the patient. Follow your facility's template.
Should I include measure scores in a discharge summary?
Yes, if you collected them. Baseline and discharge scores on the same measure, such as the PHQ-9 or GAD-7, are the clearest evidence of change against the treatment plan goals. Name the measure and the dates.
Can MentalNote write a discharge summary?
MentalNote does not have a dedicated discharge summary format. It drafts session notes in formats such as DAP, BIRP, SOAP, Progress and Intake / Biopsychosocial, and you can describe your own structure with custom instructions. You review and edit every draft.
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