Discharge Summary (Hypnotherapy Course)

Patient Name: [Patient full name]

Date of Birth: [DOB]

Medical Record Number: [MRN] (Omit if not available)

Provider: [Provider name], [Credentials]

Clinic/Organization: [Clinic or organization name]

Course Start Date: [Start date]

Course End Date: [End date]

Total Sessions Completed: [Number of sessions]

Setting: [in-person / telehealth / hybrid]

Referral Source: [Referring provider or clinic]

Reason for Referral: [Reason for referral]

Episode Synopsis

[Synopsis paragraph summarizing discharge] (State this is a discharge summary for a time-limited hypnotherapy course. Identify primary presenting concerns/targets. Indicate overall outcome as improved, partial response, limited change, or no change. State why the course ended: goal completion, planned transition, patient preference, loss to follow-up, or referral to higher level of care.)

Presenting Concerns and Baseline

Patient Goals: [Patient-stated goals at start of course] (Include brief direct quotes only if they clarify intent.)

Clinician-Framed Targets: [Symptoms, behaviors, and functional impairments targeted]

Relevant History and Context: [Pertinent medical/psychiatric history and psychosocial factors] (Include only information relevant to hypnotherapy engagement or continuity of care.)

Baseline Standardized Measures: [Measure name, score, and date for each] (If none used, state: "No formal standardized measures were administered at baseline.")

Diagnoses and Clinical Impressions

• Primary Diagnosis: [Diagnosis name] [ICD-10 code] (If outside provider scope or uncertain, document as working clinical impression and attribute source.)
• Relevant Comorbidities: [Comorbid conditions with ICD-10 codes] (Include only those materially affecting treatment; omit if none.)
• Diagnostic Uncertainties: [Differential diagnoses and recommended follow-up evaluation] (Omit if none; do not imply diagnoses through symptoms alone.)

Course of Treatment

Treatment Goals:

• [Measurable treatment goal] (List 2–5 goals targeting specific symptoms, behaviors, or functions.)

Interventions Delivered: [Summary of hypnotic interventions at functional level] (Specify induction styles: relaxation-based, focused attention, imagery-based, indirect/Ericksonian. List core components as applicable: psychoeducation, self-hypnosis training, cue-controlled relaxation, imagery rehearsal, grounding, ego-strengthening, sleep imagery, pain modulation, habit interruption. If integrated with CBT, ACT, or mindfulness, specify the role of hypnosis. Do not reproduce scripts or verbatim dialogue.)

Homework and Adherence Supports: [Recordings provided, practice schedules, adherence strategies]

Deviations from Plan: [Major changes to original plan and rationale] (Omit if none.)

Adverse Reactions: [Any dissociation, panic during induction, symptom exacerbation, or other reactions; onset/context, mitigation steps, and outcome] (State "None observed or reported" if none.)

Response to Treatment

(Document for each target problem/goal. Include baseline severity, interventions used, response/outcome with quantification when possible, residual symptoms, patient-reported and clinician-observed change, and barriers/facilitators to progress.)

• [Target problem/goal]:

  Baseline: [Severity description and/or score with date]

  Interventions: [Key techniques applied]

  Outcome: [Quantified change or functional descriptors; post-treatment score and date if available]

  Residual Symptoms: [Remaining symptoms or limitations]

  Patient-Reported Change: [Patient's perspective on improvement]

  Clinician-Observed Change: [Clinician's assessment]

  Barriers/Facilitators: [Adherence, stressors, comorbidity impact, supports]

Discharge Status and Safety

Reason for Discharge: [planned completion / early termination / administrative discharge / transfer to higher level of care / lost to follow-up] (Indicate whether mutually agreed upon.)

Current Status: [Current symptom status and functional capacity]

Self-Management Competence: [Patient's ability to independently use self-hypnosis and cue-controlled skills]

Risk Assessment: [Suicide/self-harm screening status and date; current risk level; mitigation plan if indicated] (If not assessed, state why and recommended follow-up. For elevated risk, include warning signs, coping strategies, support contacts, crisis resources, and means-safety steps discussed.)

Maintenance Plan

Self-Hypnosis Practice Plan: [Recommended frequency and duration; techniques matched to symptoms/contexts; safety instructions including not while driving, stop if distress escalates, grounding steps]

Early Warning Signs and Response: [Personalized relapse warning signs; stepwise response plan including when to seek help]

Skill Generalization: [Guidance for real-world use: bedtime routine, before anxiety-provoking situations, during cravings or pain flares]

Ongoing Supports: [Social/environmental supports; ongoing therapy or medical follow-up; booster session recommendations with criteria for return]

Follow-up and Referrals

• Recommended Follow-up: [With whom; timeframe; purpose; appointment status: scheduled on date / advised to schedule]
• Referrals Made: [Service/discipline; reason; urgency; appointment status if known] (Omit if none.)
• Pending Evaluations: [Pending items such as sleep study, psychiatry evaluation, pain clinic referral] (Omit if none.)

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[Author name], [Credentials]
[Date]