Discharge Summary (US)
Report Template:
A discharge summary records why and how an episode of care ended, drawing together the presenting problem, the course of treatment, the status of each treatment goal, outcome measure scores and the discharge plan.
This report template synthesizes information from NovoNote and NovoPsych psychometrics to assist clinicians in preparing a draft discharge summary. It captures the presenting problem and reason for treatment, treatment course and progress, each treatment goal and its status, repeated and single administration measures, and the discharge plan, including referrals, follow-up appointments and recommended strategies.
It can be used to document termination of care, or generated as a letter to another provider.
Note: the reason and manner treatment ended are stated as the source records show them, rather than assumed to be a completed course.
Discharge Summary
- Client name
- Discharge date
- Treatment period: first and last session dates
- Number of sessions
Presenting Problem and Reason for Treatment
Two to three sentences: the presenting concern and how long it had been occurring, its impact on functioning, the therapy approach or approaches used, and the diagnosis where one is documented.
Treatment Course and Progress
Brief connected paragraphs covering:
- Current clinical status
- Treatment goal progress (met, partially met, not met, ongoing), therapeutic alliance or engagement where included, and named interventions used (e.g. CBT, DBT)
- Risk assessment and management, as addressed in the sources provided
- Any setbacks or obstacles encountered
- The reason treatment ended and the manner in which it ended
Treatment Plan and Goals
- Each goal with its status (met, partially met, not met), evidenced from the sources provided
- A statement that no formal treatment goals were documented, where none are provided
Measures
- Repeated measures: name, baseline score, severity and date administered, followed by the most recent score, severity and date administered
- Single administration: name, score, severity and date administered
- Laboratory results, where the sources include these
Discharge Plan
- Referrals
- Follow-up or booster appointment schedule
- Recommended strategies (e.g. self-care, coping skills)
Discharge Summary
Client: Mary Blogs
Discharge date: August 12, 2026
Treatment period: February 4, 2026 – August 5, 2026
Number of sessions: 14
Presenting Problem and Reason for Treatment
Mary presented with persistent worry and disrupted sleep of approximately eight months’ duration, reporting reduced concentration at work. She was diagnosed with Generalized Anxiety Disorder at intake. Treatment consisted of cognitive behavioral therapy (CBT), incorporating cognitive restructuring and relaxation training.
Treatment Course and Progress
Mary engaged consistently across the treatment period, attending 14 sessions with good participation and motivation noted throughout. Cognitive restructuring targeted worry patterns, alongside relaxation training for sleep difficulty. By the final session her worry frequency and work concentration had improved to the point of goal completion, while sleep difficulty showed improvement but had not fully resolved. A brief increase in anxiety occurred in mid-June, attributed to workplace stress, with symptoms settling within two sessions. Treatment concluded as a planned completion following achievement of the primary treatment goals.
Treatment Plan and Goals
- Reduce frequency of worry episodes — Met
- Improve sleep continuity — Partially met
- Return to full concentration at work — Met
Measures
GAD-7: 16, Severe, February 4, 2026 → 6, Mild, August 5, 2026
PHQ-9: 8, Mild, February 4, 2026
Discharge Plan
- Follow-up with PCP recommended in four weeks
- Referred to a sleep hygiene resource for ongoing sleep difficulty
- Continued use of relaxation techniques recommended for stress management
- Template Type
- Report
- Session Note
- Administrative
Author:
Dr Liz Rojas
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