Discharge/Termination Summary (Psychotherapy, Older Adult)

Patient: [Full name] | DOB/Age: [DOB; age] | MRN: [Medical record number]

Provider: [Clinician name, credentials]

Episode Dates: [First session date] – [Last attended session date]

Discharge Summary Date: [Date authored]

Therapy Type: [individual / family / group]; Approach: [primary therapeutic approach(es)]; Total sessions attended: [number]; Caregiver sessions: [occurred / did not occur] (If occurred, specify relationship and frequency.)

Termination Context

[Brief narrative summary of termination context] (Include: reason for termination [planned completion / transfer of care / patient preference / administrative / non-attendance or lost to follow-up / safety or boundary termination]; whether termination was planned with a final session or unplanned; patient's stated perspective and agreement with discharge; clinician's assessment of whether discharge is clinically appropriate. If unplanned due to non-attendance, document outreach attempts with dates and final disposition. Do not infer current stability without recent contact—state the date of last direct clinical assessment and note limitations.)

Clinical Background

[Presenting problems at intake] (Summarize chief complaint and psychosocial context relevant to older adulthood as applicable—e.g., bereavement, caregiving stress, retirement transition, loneliness, role changes.)

• Baseline symptom severity and functional impact: [concise summary] (Include ADL/IADL impact if it shaped treatment goals.)
• Cognitive/medical factors affecting participation: [neurocognitive status, sensory limitations, medical comorbidities, mobility] (Note accommodations used. Omit if not applicable.)

Diagnoses at Discharge

• [DSM/ICD diagnosis with specifiers if clinically important]
• [Additional diagnoses as applicable]

(If diagnosis changed during the episode, note initial vs discharge diagnosis with rationale. If no formal diagnosis was assigned, state this with clinical rationale. If cognitive or decision-making capacity affected treatment or discharge planning, document whether formal evaluation occurred and whether a surrogate decision-maker participated.)

Treatment Provided

• Therapy approach and key components: [e.g., cognitive restructuring, behavioral activation, exposure, problem-solving, sleep strategies, relaxation, grief-focused techniques, life review]
• Adaptations for older adults: [communication accommodations, cognitive supports, caregiver involvement, pacing, sensory accommodations] (Omit if none used.)
• Care coordination: [PCP, psychiatry, social services, community resources with purpose and dates] (Omit if none occurred.)

Goals & Outcomes

(Order by clinical severity, then patient priority. If final measures unavailable due to unplanned termination, document last available scores with date and note limitations.)

[Problem/Goal 1: target symptoms or functional area]

• Interventions: [interventions linked to this problem]
• Outcome Measures: [Baseline score (date) → Discharge score (date)] (If standardized measures not used, describe clinical indicators tracked.)
• Status: [Met / Partially met / Not met / Unable to assess]
• Outcome Summary: [brief statement of improvements, residual symptoms, and functional changes]

[Problem/Goal 2: target symptoms or functional area]

• Interventions: [interventions linked to this problem]
• Outcome Measures: [Baseline score (date) → Discharge score (date)]
• Status: [Met / Partially met / Not met / Unable to assess]
• Outcome Summary: [brief statement]

(Repeat for additional goals as needed.)

Clinical Status at Discharge

• Current symptom status: [concise summary of current symptoms relative to baseline]
• Mental status: [appearance/behavior; mood/affect; thought content/process; orientation/attention; insight/judgment] (Include if ongoing symptoms, elevated risk, or handoff to another provider.)
• Current functioning: [living situation; social supports; ADL/IADL status; community engagement] (Focus on factors pertinent to aftercare.)
• Risk status: [most recent suicidal ideation status with date of last direct assessment; key risk and protective factors; clinical risk level] (If safety plan was created or updated, note where patient can access it and crisis resources provided. Address self-neglect risk if relevant—nutrition, medication adherence, ability to obtain care. If risk was never present: "No suicidal or homicidal ideation during episode; no acute safety concerns at last visit [date]." If lost to follow-up, qualify based on recency of last assessment.)
• Medications: [current psychotropic medications and prescriber] (Indicate "verified" vs "patient-reported" and direct follow-up to prescriber. Omit if not applicable or unknown.)

Discharge Plan & Aftercare

• Recommended level of care: [continue outpatient psychotherapy / step down to maintenance or booster sessions / group or support resources / no further psychotherapy indicated]
• Psychiatric follow-up: [recommended / not indicated] (Include provider if applicable.)
• Appointments scheduled: [date, provider, location] (If none, provide scheduling instructions.)
• Referrals made: [service, reason, whether records were sent]
• Care coordination completed: [PCP notified; caregiver informed if authorized; other parties with dates]
• Patient instructions: [skills to continue practicing; return precautions for worsening symptoms, suicidality, or inability to care for self; crisis resources—988, local crisis line, ED] (Note identified barriers and contingency plans.)
• Relapse prevention: [individualized early warning signs; coping/skills plan; support contacts; how to re-enter care or access booster sessions] (Include for recurrent conditions or ongoing vulnerability.)

(For unplanned terminations without a final session: provide best-available discharge plan, re-engagement instructions, urgent care guidance, and crisis resources, noting limitations due to absence of final assessment.)

Patient Preferences

[Patient's stated goals for aftercare; understanding and agreement with discharge plan; preferences regarding family/caregiver involvement and boundaries] (Use patient voice in quotations when directly stated.)

(Omit sections or bullets that are not applicable. For safety-relevant or handoff-critical fields—risk status, follow-up plan, current functioning—do not omit; instead document as "Unknown (not assessed at discharge)" with rationale, "Patient declined," or "Unavailable—discharged after no-show; last clinical assessment dated [date].")