Discharge Summary (Withdrawal Management/SUD Program)

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Patient: [Full name]    DOB: [Date of birth]    MRN: [Medical record number]

Facility/Program: [Facility name]    Unit: [Unit/Program name]

Admission: [Admission date and time]    Discharge: [Discharge date and time]

Attending Physician: [Name, credentials]    Discharging Clinician: [Name, credentials]

Discharge Disposition: [home / shelter / residential / transfer / AMA / eloped / other]

Contact for Questions: [Service phone or callback pathway for receiving clinicians]

Reason for Admission

[Two to four sentence summary stating primary reason for encounter, triggering events including last use timing, and substances involved with emphasis on those requiring medical withdrawal protocols]

Diagnoses at Discharge

(List in descending clinical priority. Mark diagnoses as provisional when certainty is limited. Do not infer psychiatric diagnoses solely from intoxication/withdrawal symptoms.)

• [Primary SUD diagnosis by substance with severity]
• [Withdrawal diagnosis by substance]
• [Co-occurring psychiatric diagnosis] (Include only if clinically relevant to safety and continuity.)
• [Pertinent medical diagnosis affecting medication choice or follow-up]

Pertinent Background

• SUD history: [Typical use pattern; last use date/time; prior withdrawal complications; prior treatments; prior MOUD exposure and response]
• Relevant medication history: [Prior MOUD dose; psychiatric medications; anticonvulsants; sedatives; pain regimen]
• Allergies: [Allergen and reaction type] (State "No known drug allergies" only if confirmed.)
• Social factors affecting safety and follow-up: [Housing stability; phone access; transportation; supports] (State "Not assessed" if unknown and materially relevant.)

Hospital Course

(Provide a concise timeline-style narrative. Avoid daily note fragments.)

Withdrawal Management: [Substances managed; assessment scales used with representative peak and final scores; salient clinical signs/symptoms; complications]

Pharmacologic Management: [Withdrawal regimen; OUD treatment decisions including buprenorphine or methadone status, induction approach and response; AUD pharmacotherapy; nicotine cessation supports; notable adverse events and rationale for medication changes]

Other Interventions: [Counseling; peer support; case management relevant to discharge planning] (Include only if applicable.)

Consultations and Key Results: [Consult services and recommendations affecting outpatient care; clinically meaningful lab/imaging results]

Condition at Discharge

• Withdrawal status: [resolved / improving]; [Last scale name and score]; [Time since last PRN withdrawal medication]
• Vital signs and mental status: [Stable / abnormal]; [Orientation; delirium status; agitation status]
• Safety risks at discharge: [Overdose risk level; suicide risk level] and [Risk-mitigation actions taken]
• If left AMA or eloped: [Last observed condition and safety counseling attempted] (Include only if applicable.)

Discharge Medications

(Include complete discharge medication list. If home medication list is unreliable, document verification methods and limitations. Only state "medications reconciled" if reconciliation actually occurred.)

Medication	Dose/Route/Frequency	Indication	Change	Duration/Quantity	Special Instructions
[Medication name]	[Dose/Route/Frequency]	[Indication]	[Start / Continue / Stop]	[Duration or Quantity]	[Special instructions]

(Add rows as needed.)

Medication reconciliation: [Sources used and limitations]

MOUD Details

(Include applicable MOUD medications with high priority.)

• Buprenorphine: [Formulation]; [Total daily dose]; [Bridging supply length]; [Induction status]; [Last dose date/time]; [Contingency plan if withdrawal or cravings recur]
• Methadone: [Verified inpatient dose]; [Last dose date/time]; [OTP name and coordination details]; outpatient continuation requires OTP
• Naltrexone: [Interval since last opioid use]; [Oral / extended-release]; [Next injection date if applicable]
• Ongoing tapers: [Exact schedule]; [End date]; [Warning signs for rebound withdrawal or oversedation]
• Sedatives co-prescribed: [Rationale]; [Duration limits] (Include only if applicable.)

Overdose Prevention Plan

(Required for opioid-involved cases; recommended for all SUD discharges.)

• Naloxone: [Prescribed / dispensed]; [Formulation]; [Quantity]; [Who was trained]; [Training confirmed: yes / no]
• Overdose risk counseling provided: [Loss of tolerance after detox/hospitalization; risks of mixing opioids with sedatives; safer-use strategies discussed]
• If naloxone not provided: [Reason and alternative plan] (Include only if applicable.)
• Harm-reduction referrals offered: [Syringe services; fentanyl test strips; community naloxone; other] (Include only if applicable.)

Follow-Up and Referrals

(Prioritize MOUD follow-up within days if initiated or changed.)

Service	Clinician/Program	Date/Time	Location	Phone	Purpose
[Service]	[Clinician/Program]	[Date/Time]	[Location]	[Phone]	[Purpose]

(Add rows as needed.)

• Recommended next level of SUD care: [Residential / IOP / OTP / Outpatient MOUD / Other] with [Brief clinical reasoning]
• Referral status: [Sent / accepted / pending]; [Warm handoff details if applicable]
• Recovery supports offered: [Mutual aid groups; peer support; community resources] and [Patient acceptance / refusal with stated reason]
• Scheduling gaps: [Responsible party]; [Expected timeframe]; [Contact method]; [Patient instructions if not contacted] (Include only if appointments not yet scheduled.)

Pending Results

(Include pending labs, cultures, toxicology, and critical results requiring follow-up even if finalized. If nothing pending, state "No pending labs or studies at discharge.")

Test	Date Obtained	Status	Responsible Clinician	Notification Method	Action if Abnormal
[Test]	[Date]	[Pending / Final]	[Name/Service]	[Call / Portal / Mail]	[Action plan]

(Add rows as needed.)

Relapse Prevention Plan

(Document patient statements and observed engagement rather than inferring motivation.)

• Patient-identified triggers and high-risk situations: [Triggers/high-risk contexts]
• Early warning signs: [Sleep disruption; cravings; contact with dealers; other]
• Coping strategies endorsed: [Skills/strategies the patient agrees to use]
• Support contacts and crisis lines: [Names/relationships and phone numbers; crisis resources]
• MOUD adherence plan: [Pharmacy; reminders; how to obtain doses/refills]
• If relapse occurs: [Harm-reduction actions and specific re-engagement plan]

Patient Education Provided

• Topics reviewed: [Medication instructions; warning signs requiring return; overdose recognition and response]
• Teach-back confirmation: [Patient demonstrated understanding / did not demonstrate understanding]
• Interpreter and materials: [Interpreter used: yes / no]; [Language of materials provided]
• If declined or left AMA: [Education attempted and patient response] (Include only if applicable.)

Signature

Author: [Name, credentials]    Date/Time: [Date and time of signature]