Therapy Discharge Summary Template and Examples

Updated: April 22, 2024

The discharge process is a critical component of overall treatment management in mental health care. A well-prepared discharge summary ensures a seamless transition from one care setting to another and also supports continued care and recovery. Let’s review the important components of a discharge summary, a simple template to use, and a few examples of the template in action.

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What is a Therapy Discharge Summary?

A discharge summary is a formal document prepared by mental health professionals that outlines the care and treatment a patient received during their stay in a facility. It includes essential information such as diagnosis, treatment progress, medications prescribed, therapy outcomes, and recommendations for follow-up care.

What makes a good visit summary

A good discharge summary is comprehensive yet concise, containing all necessary information without overwhelming the recipient. It should be clear, legible, and structured in a way that allows for scanability and quick access to important details. Key components include patient identification, admission and discharge dates, reasons for admission, treatment description, patient status at discharge, and specific follow-up care instructions.

Benefits of Using a Discharge Summary Template

The primary benefit of using a standardized patient visit summary template is to ensure consistency and completeness in documenting patient care across different providers and settings. It aids in minimizing errors and omissions, which can significantly impact patient outcomes.

How TextExpander can help write better discharge summary templates

Incorporating tools like TextExpander can significantly enhance the efficiency of creating patient visit summaries. TextExpander allows healthcare professionals to use predefined snippets to quickly insert common phrases and data fields, thus reducing typing errors and saving time.

Therapy Discharge Summary Template and Examples

Below is a generic template for a therapy discharge summary followed by three filled-in examples to illustrate how it can be adapted for different scenarios.

Therapy Discharge Summary Template Copy Snippet Copied!

Patient Information:
Name: [Name]
ID: [Patient ID]
Date of Birth: [DOB]
Admission Date: [Admission Date]
Discharge Date: [Discharge Date]
Diagnosis: [Primary Diagnosis]

Treatment Summary:

Treatment Provided: [Details of the treatment modalities used]
Response to Treatment: [Patient’s response to the treatment]
Medications Prescribed: [List of medications including dosages]

Condition at Discharge:

Mental Status: [Details of patient’s mental status at discharge]
Physical Health: [Details of patient’s physical health if relevant]
Follow-up Care:

Follow-up Appointments: [Details of scheduled or recommended follow-up appointments]
Continuing Care Recommendations: [Specific recommendations for ongoing treatment]

Provider Information:
Name: [Provider Name]
Contact: [Provider Contact Information]

Therapy Discharge Summary Examples

Example 1: Depression Copy Snippet Copied!

Patient Information:
Name: John Doe
ID: 001234567
Date of Birth: 01/01/1990
Admission Date: 01/15/2023
Discharge Date: 03/15/2023
Diagnosis: Major Depressive Disorder

Treatment Summary:

Treatment Provided: Individual CBT sessions, group therapy
Response to Treatment: Significant improvement in depressive symptoms
Medications Prescribed: Sertraline 100 mg daily

Condition at Discharge:

Mental Status: Stable with improved mood
Physical Health: Good

Follow-up Care:

Follow-up Appointments: Monthly follow-up with a psychiatrist
Continuing Care Recommendations: Continue with CBT, regular exercise, and medication management

Provider Information:
Name: Dr. Emily Smith
Contact: esmith@clinic.com

Example 2: Anxiety Disorder Copy Snippet Copied!

Patient Information:
Name: Alice Johnson
ID: 002345678
Date of Birth: 02/02/1985
Admission Date: 02/20/2023
Discharge Date: 04/20/2023
Diagnosis: Generalized Anxiety Disorder

Treatment Summary:

Treatment Provided: Cognitive Behavioral Therapy, mindfulness exercises
Response to Treatment: Reduced anxiety levels, better coping strategies
Medications Prescribed: None

Condition at Discharge:

Mental Status: Calm, able to manage anxiety effectively
Physical Health: Stable

Follow-up Care:

Follow-up Appointments: Bi-weekly sessions with a clinical psychologist
Continuing Care Recommendations: Maintain mindfulness practice, possibly explore medication if symptoms increase

Provider Information:
Name: Dr. Robert Brown
Contact: rbrown@healthcare.com

Example 3: Bipolar Disorder Copy Snippet Copied!

Patient Information:
Name: Claire Thomas
ID: 003456789
Date of Birth: 03/03/1980
Admission Date: 03/01/2023
Discharge Date: 05/01/2023
Diagnosis: Bipolar Disorder Type I

Treatment Summary:

Treatment Provided: Mood stabilization therapy, psychoeducation
Response to Treatment: Mood stabilized, better engagement in daily activities
Medications Prescribed: Lithium Carbonate 300 mg twice daily

Condition at Discharge:

Mental Status: Mood stable with periodic monitoring
Physical Health: Monitored for lithium side effects

Follow-up Care:

Follow-up Appointments: Weekly check-ups for the first month
Continuing Care Recommendations: Regular blood tests for lithium levels, continue mood stabilization therapy

Provider Information:

Name: Dr. Karen Lee
Contact: klee@mentalhealth.com

What is TextExpander

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With TextExpander, you can store and quickly expand full email templates, email addresses, and more anywhere you type. That means you’ll never have to misspell, memorize, or type the same things over and over again.

Patient Information: <br>Name: [Name] <br>ID: [Patient ID] <br>Date of Birth: [DOB] <br>Admission Date: [Admission Date] <br>Discharge Date: [Discharge Date] <br>Diagnosis: [Primary Diagnosis] <br> <br>Treatment Summary: <br> <br>Treatment Provided: [Details of the treatment modalities used] <br>Response to Treatment: [Patient’s response to the treatment] <br>Medications Prescribed: [List of medications including dosages] <br> <br>Condition at Discharge: <br> <br>Mental Status: [Details of patient’s mental status at discharge] <br>Physical Health: [Details of patient’s physical health if relevant] <br>Follow-up Care: <br> <br>Follow-up Appointments: [Details of scheduled or recommended follow-up appointments] <br>Continuing Care Recommendations: [Specific recommendations for ongoing treatment] <br> <br>Provider Information: <br>Name: [Provider Name] <br>Contact: [Provider Contact Information]
Patient Information: <br>Name: John Doe <br>ID: 001234567 <br>Date of Birth: 01/01/1990 <br>Admission Date: 01/15/2023 <br>Discharge Date: 03/15/2023 <br>Diagnosis: Major Depressive Disorder <br> <br>Treatment Summary: <br> <br>Treatment Provided: Individual CBT sessions, group therapy <br>Response to Treatment: Significant improvement in depressive symptoms <br>Medications Prescribed: Sertraline 100 mg daily <br> <br>Condition at Discharge: <br> <br>Mental Status: Stable with improved mood <br>Physical Health: Good <br> <br>Follow-up Care: <br> <br>Follow-up Appointments: Monthly follow-up with a psychiatrist <br>Continuing Care Recommendations: Continue with CBT, regular exercise, and medication management <br> <br>Provider Information: <br>Name: Dr. Emily Smith <br>Contact: esmith@clinic.com
Patient Information: <br>Name: Alice Johnson <br>ID: 002345678 <br>Date of Birth: 02/02/1985 <br>Admission Date: 02/20/2023 <br>Discharge Date: 04/20/2023 <br>Diagnosis: Generalized Anxiety Disorder <br> <br>Treatment Summary: <br> <br>Treatment Provided: Cognitive Behavioral Therapy, mindfulness exercises <br>Response to Treatment: Reduced anxiety levels, better coping strategies <br>Medications Prescribed: None <br> <br>Condition at Discharge: <br> <br>Mental Status: Calm, able to manage anxiety effectively <br>Physical Health: Stable <br> <br>Follow-up Care: <br> <br>Follow-up Appointments: Bi-weekly sessions with a clinical psychologist <br>Continuing Care Recommendations: Maintain mindfulness practice, possibly explore medication if symptoms increase <br> <br>Provider Information: <br>Name: Dr. Robert Brown <br>Contact: rbrown@healthcare.com
Patient Information: <br>Name: Claire Thomas <br>ID: 003456789 <br>Date of Birth: 03/03/1980 <br>Admission Date: 03/01/2023 <br>Discharge Date: 05/01/2023 <br>Diagnosis: Bipolar Disorder Type I <br> <br>Treatment Summary: <br> <br>Treatment Provided: Mood stabilization therapy, psychoeducation <br>Response to Treatment: Mood stabilized, better engagement in daily activities <br>Medications Prescribed: Lithium Carbonate 300 mg twice daily <br> <br>Condition at Discharge: <br> <br>Mental Status: Mood stable with periodic monitoring <br>Physical Health: Monitored for lithium side effects <br> <br>Follow-up Care: <br> <br>Follow-up Appointments: Weekly check-ups for the first month <br>Continuing Care Recommendations: Regular blood tests for lithium levels, continue mood stabilization therapy <br> <br>Provider Information: <br> <br>Name: Dr. Karen Lee <br>Contact: klee@mentalhealth.com

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