Discharge (Termination) Notes: Ensuring a Smooth Transition for Clients

Therapists don’t stop caring about their clients when services end. We continue to hold them in our hearts, root for them from afar, and want to provide the best possible transition out of treatment as a way for our care to have a long-lasting positive impact.

The end of therapy is a critical stage in the therapeutic process and one that demands thoughtfulness and attention to detail. It requires planning and careful execution to ensure that clients leave care feeling they can and want to return to therapy in the future, should the need arise. In addition to having meaningful termination sessions and offering transitional objects when appropriate, a smooth discharge from therapy also includes thoughtful clinical documentation in the form of a discharge note.

What is a discharge note and how to write a discharge summary?

A discharge note, also called a termination note, is a written summary held in the client’s chart of what happened during the time the client was in your care. A progress note typically uses a SOAP or GIRP format and documents weekly sessions. A discharge note, on the other hand, spans a broader amount of time and gives a high-level view of the client’s treatment.

To write a discharge note we can include:

• Reasons for termination, including referrals to new providers
• Symptoms at the time of intake
• Initial reasons for seeking treatment
• Diagnosis
• Treatment goals, past and present
• Modalities and interventions used and how the client responded
• Progress (or lack thereof) made during treatment

The discharge note also includes recommendations for future mental health care needs and referrals to help the client follow through on these recommendations. Essentially, this note is a TL;DR or Cliff’s Note version of the time they spent in therapy, along with your thoughts on where they should go from here.

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Discharge Note Example and Template:

Here is an example of a discharge note for Kevin McAllister, aka Macaulay Cullkin’s character on Home Alone.

DISCHARGE NOTE

Client: Kevin McAllister

Reason for Termination: The client achieved goals.

Chief Complaint: The client and his mother initially presented to treatment following the client experiencing symptoms of nightmares, restlessness, and angry outbursts. The client’s mother reported client showed signs of separation anxiety, such as clinginess and school refusal. The client reported at the time of intake experiencing fear-based thoughts around being abandoned, difficulty concentrating, and no longer finding pleasure in activities he used to enjoy. The client and mother reported symptoms began 2 weeks ago, following an incident where the client was forgotten at home as his family went on an international vacation without him. The client and his mother reported that during this time client was left alone, he had to fend off violent house intruders by himself.

Most Recent Diagnosis:

Acute Stress Disorder 308.3 (F43.0)

Separation Anxiety Disorder 309.21 (F93.0)

Treatment modality and interventions:

The therapist met with the client weekly, which included individual and family sessions. The therapist facilitated EMDR therapy to support the client in healing from traumatic experiences. Family sessions focused on supporting family members in communicating thoughts and feelings with one another about the client being left home alone and safety planning to support the client in regaining a sense of security in the home.

Treatment Goals and Outcome:

The client’s primary treatment goal was to sleep through the night without nightmares seven times a week. The client reported meeting the goal. The client and his mother reported improvements in mood, engagement in extracurricular activities, and concentration at the end of treatment as well. Discussed upcoming family plans to travel to NYC. The client and family expressed a sense of hopefulness that this trip would be a positive experience for all of them.

Recommendations:

The therapist recommends client return to therapy in the future if symptoms return.

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Why is a discharge note important?

No therapist goes into the field of mental health care because they love clinical documentation. On the contrary, it's often something we avoid doing. We procrastinate on this task because the process is time-consuming and painful when you’re not relying on AI psychotherapy note software, like Mentalyc, to assist the process (more on Mentalyc later).

But as one of my clinical supervisors used to say, good clinical documentation is part of good clinical care. We have a duty to provide quality services to those we work with. Clinical documentation is a necessary part of serving our clients, and the discharge note is no different.

Discharge notes are important for many reasons.

1. They provide a quick recap of the client’s progress and goals achieved (or not achieved) during therapy. Reviewing this information with clients helps you both see where you’ve been together and what has been accomplished.
2. They give you guidance on what to do following termination. This may include communicating referrals to group therapy or other step-down services, information about recovery groups, encouragement to engage in self-care practices, and reminders about coping strategies for mental health symptoms that may arise from time to time. You can also include information for the client about how they will know if it's time to return to therapy in the future and if so, what to do.
3. It informs the client’s future mental health care. This brief version of the client’s past mental health treatment with recommendations for the future clearly outlined will be an asset for any subsequent provider, whether it's you or another mental health care professional.
4. Psychotherapy notes, including discharge notes, can serve special legal purposes. Because of this, it’s imperative that Progress Notes and discharge notes are thoughtfully written in a timely manner. They are a record that can be used in any future legal proceedings, even if you don’t want them to be. You can never be entirely certain that a client’s notes will never be subpoenaed or used in court, even if you deem that highly unlikely. Having an up-to-date, clear, and thorough clinical record for each client is the best practice and may protect you in the long run.
5. There is a growing movement backed by research for patients to own or at least have access to easily view their healthcare records online.* Proponents say this allows for greater patient autonomy as well as easier access to allow providers access to one another’s records. The purpose that we know notes to serve today may change as technology and patient needs to continue to develop.

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CAN DISCHARGE NOTES REALLY FACILITATE A SMOOTHER TRANSITION OUT OF CARE?

Short answer: yes!

Longer answer: When we are thinking about clinical documentation, this can seep into how a client feels taken care of in their relationship with us. Quality discharge notes can extend those positive vibes beyond our current interactions and far into the future. If you’ve ever had a good service provider go the extra mile for you, you know that it feels good to have someone looking out for you and your best interests. You have less to worry about when you know that provider is doing everything they can to serve you well. That’s what a good discharge note does. It lets the client know you’re there, working hard with and for them, even to the very end.

Discharge notes lay out a clear picture of the client's starting point, goals, and progress achieved along the way. This understanding can help clients feel empowered and motivated to continue taking care of their relationships and emotional well-being after counseling has ended.

Additionally, if the client were to change providers in the future, the Discharge Note provides a clear picture of past mental health care with your treatment recommendations for the future. This makes the process for the client to transition to a new mental health provider much more seamless.

What about clients who drop out without a termination session?

This might feel obvious, but a therapist cannot verbally review future mental health care recommendations with clients who are no longer attending sessions. This is one of the many reasons it can be frustrating when clients drop out of treatment with no warning. This is not an ideal circumstance, to say the least. In these situations, though, a therapist must still do the best they can to do what is right for the client. This means, serving them well by keeping proper clinical documentation.

So yes, even clients who drop out of treatment should have a discharge note in their records. This is for a number of reasons, including:

• The client may come back in the future.
• There may be a request for notes from other mental health providers to coordinate care.
• In very unfortunate and, hopefully, unlikely circumstances, the client may begin legal proceedings against the therapist. Should any legal issues arise in the future, the best protection a therapist can have is proper and timely clinical documentation.

BUT WHAT IF I’M ALREADY OVERWHELMED WITH CLINICAL DOCUMENTATION?

Discharge notes, like all clinical documentation, are a vital part of quality clinical care and can help ensure a smooth transition out of therapy.

The need for the discharge note doesn’t make writing it any easier. But Mentalyc can.

Mentalyc is a powerful tool for mental health professionals that can be a helpful resource for writing thorough clinical documentation, including discharge notes while saving time. This web-based application is HIPAA-compliant and uses artificial intelligence to help therapists create high-quality clinical notes quickly and easily.

A thoughtful discharge Note that historically may have taken a therapist 20–30 minutes to write. Not to mention adding 30–40 more minutes for the therapist to review each of the past treatment plans and progress notes to get a refresher on the entire course of treatment, treatment goals, past modalities used, and how the client responded.

With Mentalyc, the process becomes much quicker. This software reviews and compiles data from past sessions, assessments, and treatment plans and then offers an initial draft version of the discharge note. The therapist reviews the note, makes any desired changes, and signs off. The process takes only a few minutes of the therapist’s precious time.

FINAL THOUGHTS

Going through and reflecting on someone’s treatment and our therapeutic relationship with them and engaging in an intentional clinical documentation process, is also helpful for the therapist in processing emotions about the therapeutic relationship ending. We are emotional beings who use ourselves as a tool throughout the course of the relationship. It makes sense that we would benefit from a way to process our experience with the client. The discharge note is our opportunity for closure and to express care for the client one last time. Because, as we know, they’ll be in our hearts for a long time to come.

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About the author

Ann Dypiangco

Ann Dypiangco, LCSW is a mental health therapist and tech enthusiast who specializes in perinatal mental health and trauma. With a master's degree from Boston College, Ann has extensive training in psycho-sensory techniques such as EMDR and Havening. She is licensed in California and runs a small virtual practice. Ann is passionate about the intersection of technology and mental health and is excited about how AI and the metaverse will transform the industry.

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