A therapy discharge summary documents the conclusion of treatment and provides a comprehensive record of a client's therapeutic journey, progress, and recommendations for future care. This essential piece of clinical documentation ensures continuity of care when clients transition to other providers or complete treatment goals.

Key Takeaways

• Discharge summaries serve as both clinical and legal documentation that capture treatment outcomes, progress toward goals, and recommendations for ongoing care or future treatment needs

• Essential components include client demographics, reason for discharge, treatment summary, current status, and follow-up recommendations to ensure comprehensive documentation of the therapeutic process

• Completing discharge summaries protects both clients and clinicians by providing clear records of care provided, treatment outcomes, and professional recommendations for future support

What Is a Therapy Discharge Summary?

A therapy discharge summary is a formal clinical document that captures key information at the end of a client's treatment episode. Unlike progress notes that document individual sessions, discharge summaries provide a comprehensive overview of the entire treatment journey from intake through termination.

These summaries serve multiple important functions in clinical practice. They document treatment outcomes for insurance companies, support continuity of care when clients transfer to new providers, and provide legal protection by creating a clear record of services rendered. When done well, discharge summaries also help clients understand their progress and provide clear guidance for maintaining their gains.

Discharge summaries are distinct from psychotherapy notes (process notes), which receive special privacy protections under HIPAA. While psychotherapy notes contain your personal impressions and analysis, discharge summaries are part of the official medical record and must focus on objective clinical information.

Components of a Discharge Summary

Creating comprehensive discharge documentation requires including specific elements that meet clinical, legal, and insurance requirements.

Client Identifying Information

Every discharge summary begins with basic identifying information:

• Client's full name and date of birth

• Complete dates of treatment (first and last session)

• Primary diagnosis with ICD-10 codes

• Treatment setting and level of care provided

Reason for Discharge

Clearly documenting why treatment ended helps future providers understand the context. Common discharge reasons include:

Treatment goals met: Client successfully achieved treatment objectives and no longer requires the current level of care.

Client choice/termination: Client decided to end treatment for personal, financial, or other reasons.

Transfer to different level of care: Client requires more intensive services or is stepping down to less intensive support.

Administrative discharge: Treatment ended due to insurance authorization ending, client moving, or practice closure.

Loss of contact: Client stopped attending sessions without notification.

Treatment Summary

This section captures the therapeutic work completed:

• Presenting problems and initial symptoms at intake

• Therapeutic approaches used (CBT, DBT, EMDR, etc.)

• Frequency and duration of sessions

• Significant interventions that were helpful

• Progress toward treatment goals

Current Status and Outcomes

Document the client's clinical presentation at discharge:

• Symptom improvement using specific measures when possible

• Current functioning level in daily activities, relationships, and work

• Goals achieved versus not achieved

• Risk assessment including safety concerns and protective factors

Follow-Up Recommendations

Clear recommendations help clients maintain gains:

• Continuing care needs and recommended frequency

• Referrals to other providers or services

• Medication management recommendations

• Self-care and relapse prevention strategies

• Crisis resources provided

Therapy Discharge Summary Template

CLIENT INFORMATION Name: [Full name] Date of Birth: [DOB] Dates of Service: [Start date] to [End date] Total Sessions: [Number] Primary Diagnosis: [ICD-10 code and description]

REASON FOR DISCHARGE [Brief explanation of why treatment ended]

PRESENTING PROBLEM [Description of symptoms and concerns at intake]

TREATMENT SUMMARY Therapeutic approach: [Primary modality] Session frequency: [Weekly/biweekly] Key interventions: [Main techniques used] Progress toward goals: [Status of each goal]

CURRENT STATUS Symptoms: [Current presentation] Functioning: [Work, relationships, self-care] Risk assessment: [Safety status]

FOLLOW-UP RECOMMENDATIONS [Specific recommendations for ongoing care, referrals, self-care, and crisis resources]

Provider Information [Your name, credentials, and date]

Sample Discharge Summary Examples

Example 1: Successful Treatment Completion

Sarah completed 16 sessions over four months for depression. She came in struggling with low mood, withdrawing from friends, and negative thoughts about herself. Through CBT, she learned to challenge her thinking patterns and started getting active again. Her depression symptoms went from moderate-severe to mild, and she's back to her usual activities. She feels ready to manage on her own and knows she can return if needed.

Example 2: Client-Initiated Termination

Michael attended six sessions for anxiety before ending treatment due to work conflicts and money concerns. He learned some basic relaxation techniques and saw some improvement, but still has significant anxiety that wasn't fully addressed. We discussed that he'd benefit from continuing therapy when his situation allows. He has information about lower-cost options and knows he can come back.

Example 3: Transfer to Higher Level of Care

Jennifer's depression got worse over four weeks despite therapy. She developed more serious suicidal thoughts and agreed she needs more support than weekly sessions can provide. She's starting an intensive outpatient program that meets daily and includes medication management. The plan is for her to return to individual therapy once she's doing better in the program.

Frequently Asked Questions

How long should a discharge summary be?

Most discharge summaries are one to two pages. Brief treatment might need only one page, while longer or more complex cases might need more detail. The key is including everything important without being excessive. Focus on what matters clinically rather than hitting a specific length.

When should I complete the discharge summary after the last session?

Complete your discharge summary within a week of the last session while everything is still fresh. For planned endings, aim for 3-5 business days. This protects you legally and makes sure you don't forget important details about how things ended or what you recommended.

Do I need a discharge summary if the client ghosts me?

Yes. Document when you last saw them, note they stopped coming without telling you, describe your attempts to reach them, and record what you'd recommend based on your last session. This protects you if questions come up later about their care.

Takeaway

Discharge summaries are essential documentation that serves your clients, future providers, and your practice. They capture the work you did together, document outcomes clearly, and provide helpful guidance for what comes next.

Good discharge notes show your clinical skills, support continuity of care, and protect you professionally. Consider creating templates that include all the necessary pieces while leaving room for what's unique about each client.

Tools like Berries can help streamline your discharge documentation by organizing information from your clinical notes throughout treatment. With the right template and good habits, you can create discharge summaries that honor the therapeutic work while meeting professional standards.

Sources

1. U.S. Department of Health & Human Services. (n.d.). HIPAA Privacy Rule and Sharing Information Related to Mental Health. https://www.hhs.gov/sites/default/files/hipaa-privacy-rule-and-sharing-info-related-to-mental-health.pdf

2. TheraPlatform. (n.d.). Therapy discharge plan. https://www.theraplatform.com/blog/1011/therapy-discharge-plan

3. ICANotes. (2025). Mental Health Discharge Summary Sample: What "Good" Looks Like. https://www.icanotes.com/2025/05/22/mental-health-discharge-summary-sample/

4. U.S. Department of Health & Human Services. (2017). Does HIPAA provide extra protections for mental health information compared with other health information? https://www.hhs.gov/hipaa/for-professionals/faq/2088/does-hipaa-provide-extra-protections-mental-health-information-compared-other-health.html

5. OptimisPT. (2024). Required Elements of a Discharge Summary. https://optimispt.com/considerations-for-required-elements-of-a-discharge-summary/

6. Documentation Wizard. (2025). Are Discharge Summaries Mandatory? https://documentationwizard.com/are-discharge-summaries-mandatory/

7. Blueprint. (n.d.). Discharge Progress Notes Examples and Templates: Streamlining Documentation for Therapists. https://www.blueprint.ai/blog/discharge-progress-notes-examples-and-templates-streamlining-documentation-for-therapists

8. ICANotes. (2023). Mental Health Documentation Guidelines & Cheat Sheet. https://www.icanotes.com/2023/03/03/behavioral-health-documentation-best-practices/

Disclaimer: This article is for informational purposes only and is not a substitute for professional clinical judgment, supervision, or continuing education. Therapists should consult current clinical guidelines, state regulations, and insurance requirements when creating discharge documentation and use their professional discretion when applying this information to individual client cases.