Discharge/Termination Summary (Behavioral Health in Medical Setting)

Note Type: Discharge/Termination Summary—Behavioral Health in Medical Setting

Author and Credentials: [Author name, degree(s), license number if applicable]

Service or Program: [Service/Program name and site]

Episode Dates: [First behavioral health contact date] – [Last behavioral health contact date]

Total Duration: [Total number of visits] visits; [Total clinical time in minutes/hours] (Include direct care and care coordination time if tracked.)

Modality and Setting: [inpatient / outpatient]; [in-person / telehealth / hybrid]

Interpreter Used: [yes / no] (If yes, include language and interpreter type: [in-person / phone / video].)

Intended Recipients: [Receiving clinician/team names and roles]

Reason for Termination: [completed treatment / stepped up / stepped down / transferred / patient preference / administrative / lost to follow-up] (Add brief context as needed.)

Referral and Presenting Problem

[Referral source and specific consult question] (Begin with who referred and the explicit consult question or purpose.)

[Core presenting concerns at episode start and impact on medical care] (Describe how symptoms or behaviors affected adherence, pain coping, procedure tolerance, or rehab participation. Include only psychosocial context relevant to treatment planning.)

Initial risk/safety baseline: [Suicide/self-harm and violence risk assessment findings, or "Not assessed" with rationale]

Diagnoses and Clinical Formulation

(Include this section when diagnoses were formally established during the episode. For brief or consultative episodes without formal diagnostic assessment, this section may be omitted or replaced with Clinical Impression only.)

Diagnoses: [Behavioral health diagnoses with DSM/ICD codes]

Clinical Formulation: [3–5 sentence working formulation linking maintaining factors to symptoms and medical context; include strengths, protective factors, and relevant medical factors such as pain, sleep, medication effects, or cognitive considerations]

Clinical Impression (if no formal diagnosis): [Concise impression with level of certainty and rationale]

Course of Care

• Dose of services: [Number of visits]; [Attendance pattern—completed/cancelled/no-shows]; [Key transitions during episode]
• Interventions delivered: [Psychoeducation topics]; [Skills taught—e.g., breathing retraining, behavioral activation, stimulus control, cognitive restructuring]; [Approaches—CBT / ACT / MI / DBT-informed / other]; [Care coordination activities]
• Engagement and response: [Patient participation and response]; [Barriers encountered]; [Patient-stated preferences]; [Offered/declined interventions with reasons if known]

Outcomes

Patient-centered goals at discharge:

• [Goal 1] — [Achieved / Partially achieved / Not achieved / Deferred]
• [Goal 2] — [Achieved / Partially achieved / Not achieved / Deferred] (Add items as needed.)

Functional outcomes relevant to medical care: [e.g., dialysis attendance, PT/OT participation, medication adherence, procedure tolerance]

Standardized measures:

Measure	Baseline Score (date)	Final Score (date)
[Measure name]	[Score (MM/DD/YYYY)]	[Score (MM/DD/YYYY)]

[Brief interpretation of trajectory] (If measures were not collected, state reason: single-session consult, acute delirium, language barrier, patient declined, or other.)

Clinician summary of trajectory: [Brief narrative of symptom change and functional impact with attribution to likely contributing factors]

Adverse events or crises during episode: [ED visits / psychiatric admissions / self-harm events / safety escalations, or "None"] (Document factually if present.)

Current Status

• Symptoms: [Current symptom status and severity]
• Function: [Work/school/ADLs]; [Ability to follow medical plan]
• Mental status (focused): [Relevant elements: appearance/behavior, mood/affect, thought process/content, orientation, insight/judgment] (Include only elements relevant to ongoing management. If no formal MSE performed, state explicitly.)
• Cognitive status: [Cognitive screening/observations relevant to self-management and reliability of follow-through] (Include only if relevant.)
• Medication status: [Current psychotropics with adherence notes and prescriber] / [Medication management handled by [provider/service]; no medication changes made by BH service]

Risk Assessment and Safety

(Include this section whenever risk was identified or assessed at any point. If never assessed, state "Risk assessment not performed" with rationale and note crisis guidance provided. If current risk status is unknown at termination, state "Unable to assess current risk status" and document outreach attempts and resources provided.)

• Suicide/Self-harm risk: [Denies / Endorses] ideation; [Plan]; [Intent]; [Recent or past behaviors]; [Acute risk factors]; [Chronic risk factors]; [Protective factors]; [Overall risk level per organizational stratification]
• Violence risk: [Denies / Endorses] ideation or behaviors; [Specific risks or contexts]; [Overall risk level] (Include only if assessed.)
• Substance-related safety: [Current use patterns]; [Intoxication/withdrawal concerns]; [Medication interactions or overdose risk] (Include only if relevant.)
• Safety plan: [Warning signs]; [Internal coping strategies]; [Social supports]; [Professional resources]; [Means safety steps taken] (Include if safety plan exists.)
• Crisis instructions provided: [ED/911 guidance]; [Crisis line]; [After-hours coverage]

Remaining Needs and Relapse Prevention

• Unresolved problems and monitoring needs: [List items ordered by clinical priority]
• Barriers to ongoing care: [Transportation / cost / cognitive limitations / social instability / language / other] (List only applicable items.)
• Relapse prevention plan: [Individualized early warning signs]; [Skills to continue practicing]; [Maintenance recommendations]; [When to seek help and from whom]
• Ongoing measurement: [Measure name]; [Frequency]; [Who reviews and acts on results] (Include when applicable.)

Handoff and Follow-Up

• Receiving clinician/team: [Name(s) and role(s)]
• Responsibilities at handoff:
  • Medication management: [Responsible clinician/service]
  • Ongoing psychotherapy (if any): [Modality/focus and responsible clinician/service]
  • Safety monitoring: [Responsible clinician/service and parameters]
  • Follow-up of pending items: [Owner and timeframe]
• Follow-up appointments: [Date/time/location if scheduled] / [Not scheduled—plan, responsible party, and target timeframe]
• Pending items: [Labs / imaging / consults / referrals / resource applications] — [Expected completion] — [Owner for follow-up]
• Transmission of this summary: [EHR routing / secure message / phone handoff / fax] (Include date and recipient.)
• Patient/caregiver communication: [Key instructions reviewed]; [Understanding confirmed]; [Caregiver involvement]
• If administrative termination or lost to follow-up: [Last completed visit date]; [Outreach attempts with dates and methods]; [Safety concerns at last contact]; [Referrals and crisis resources communicated]; [Instructions for re-engagement]

Signature

_____________________________________
[Author name], [Credentials] — [Date/Time]

Co-signature (if applicable): _____________________________________
[Supervising clinician name], [Credentials] — [Date/Time]