Substance Use Disorder Discharge Summary & Continuing Care Plan

Patient: [Full legal name; DOB; MRN; preferred name/pronouns if applicable]

Program/Facility: [Facility name; address; main phone]

Level of Care: [withdrawal management / residential / PHP / IOP / outpatient / OTP / other]

Admission Date: [Date; time if clinically relevant]

Discharge Date: [Date; time if clinically relevant]

Discharging Clinician: [Name; credentials; contact]

PCP/Primary Outpatient Providers: [PCP; OTP; psychiatrist; therapist; other—include names and contact info if available]

Emergency Contact: [Name; relationship; phone]

Discharge Snapshot

(Use short bullet phrases, not paragraphs. Prioritize safety-critical items.)

• Primary SUD + Comorbidities: [Primary SUD diagnosis(es) with severity; key psychiatric/medical comorbidities]
• Disposition: [home / transfer / higher level of care / AMA / administrative] — [brief rationale]
• Suicide/Self-Harm Risk: [low / moderate / high] — [one-line rationale; screening tool referenced]
• Overdose Risk: [low / moderate / high] — [one-line rationale: tolerance loss, polysubstance, prior overdose, sedatives, etc.] (Always include for opioid-involved patients.)
• MOUD Status: [medication; dose; formulation; continuation/bridging plan] or [declined—shared decision-making documented] or [not indicated]
• Naloxone: [provided / prescribed / declined]; [formulation]; [training documented: yes / no]
• Next Appointments: [Date/time; provider/service; location/telehealth; purpose] (List all scheduled.)
• Crisis Contacts: [Program number]; 988; [ED/911 instructions]

Diagnoses

(Use standardized terminology. Specify severity for SUD. Include only conditions affecting treatment, risk, or follow-up.)

• SUD Diagnoses: [Diagnosis with severity, e.g., opioid use disorder, severe; alcohol use disorder, moderate]
• Co-occurring Psychiatric Diagnoses: [Diagnoses with specifiers if relevant]
• Key Medical Diagnoses: [Conditions affecting care or risk—pregnancy status; chronic pain; hepatitis C; HIV; other]
• Tobacco/Nicotine Use: [present / absent; diagnosis if applicable]
• Allergies/ADRs: [Medication; reaction; severity]
• Uncertain Diagnoses: [working diagnosis / rule out] — [brief rationale or pending data] (Omit if none.)

Reason for Admission

[Trigger for this episode: relapse/overdose/withdrawal risk/psychosocial crisis/legal mandate/other; referral source]

[Patient-stated goals at admission in their own terms] (Keep to 1–2 concise paragraphs; reference prior assessments if needed rather than repeating extensive history.)

Treatment Course Summary

[Concise narrative of course of care, including level(s) of care, overall response, notable complications, and handoffs]

• Levels of Care + Dates: [Start–end for each level, including any step-up/step-down]
• Significant Clinical Events: [Withdrawal complications; overdose during episode; ED transfers; major medication changes; critical lab/imaging results] (Omit if none.)
• Treatment Modalities: [Individual counseling; group therapy; family sessions; peer support; case management; other]
• Monitoring Summary: [Toxicology pattern interpretation; validated screening trends—summarize patterns rather than listing every test]
• Engagement/Attendance: [Overall participation pattern; barriers; accommodations]

Progress Toward Goals

(Create a subsection for each active treatment goal. State what was measured and when; attribute evidence to its source. If goals not met, document nonjudgmentally and include re-engagement plan.)

[Goal 1 statement]

• Interventions Delivered: [Modalities and frequency relevant to this goal]
• Measured Progress: [Objective/subjective measures with dates; evidence source: patient report / toxicology / observed dosing / attendance records / validated scales]
• Current Barriers: [Cravings; triggers; mental health symptoms; medical issues; housing/transportation; legal/employment; access]
• Next-Step Recommendations: [Specific actions, referrals, frequency, adjustments]

[Goal 2 statement]

• Interventions Delivered: [Details]
• Measured Progress: [Details]
• Current Barriers: [Details]
• Next-Step Recommendations: [Details]

(Add additional goal sections as needed.)

Clinical Status at Discharge

• Mental Status: [Appearance/behavior; mood/affect; thought process/content including psychosis, mania, SI/HI; cognition; judgment/insight] (Highlight acute safety features.)
• Withdrawal/Intoxication: [present / absent]; [last reported use with date/time]; [objective signs/scale scores if used]
• Medical Stability: [Vitals if relevant; pregnancy status; acute issues; pain control; infectious disease status]
• Functional/Safety Capacity: [Orientation; ability to follow instructions; medication self-management; supports available at discharge]

Risk Assessment and Safety Planning

(Document risk level, concise rationale, and mitigation for each domain. If patient declines any assessment, document "patient declined" and mitigation offered.)

Suicide/Self-Harm

• Screening/Assessment: [Tool or clinical assessment used]
• Current SI/Intent/Plan: [present / absent]; [details if present]
• Acute Risk Level: [low / moderate / high] — [brief rationale]
• Protective Factors: [Family/supports; reasons for living; treatment engagement]
• Safety Plan: [created / updated at discharge: yes / no]; [lethal means counseling addressed: yes / no]
• Crisis Contacts: [Program number]; 988; [ED/911 instructions]

Overdose Risk

• Risk Factors: [Tolerance loss; polysubstance; prior overdose; sedative co-use; medical comorbidity; solitary use; recent discharge]
• Overdose Education: [provided: yes / no]; [key points covered]
• Naloxone: [provided / prescribed / declined]; [formulation]; [who trained]; [storage instructions provided: yes / no]

Relapse/Withdrawal Risk

• Relapse Risk Level: [low / moderate / high] — [primary drivers]
• Withdrawal Risk: [low / moderate / high] — [substance-specific considerations if stopping/unstable use]
• Mitigation Steps: [MOUD/medication adjustments; coping strategies; support plan; close follow-up]

Violence Risk

(Only include if clinically indicated.)

• Threats/Intent toward Others: [present / absent]; [details if present]
• Access to Weapons: [yes / no / unknown]
• Mandated Reporting/Notifications: [completed / pending / not applicable]
• Mitigation: [Measures taken; coordination with security/law enforcement if applicable]

Medications at Discharge

Medication Reconciliation Statement: Discharge medications reconciled against best available pre-admission list ([sources used: patient report / pharmacy / PDMP / OTP verification]). Discrepancies resolved and counseling provided.

• Medication: [Name; dose; route; frequency] — Indication: [Reason]
  Status: [continued / new / discontinued] — [reason for change if applicable]
  Quantity/Refills: [Number dispensed and refills authorized]
  Pharmacy/Access Plan: [Pharmacy name; delivery/pickup; prior auth/copay assistance if relevant]
• (Repeat for each medication.)

MOUD Details (when OUD present): [Medication type and formulation; last dose date/time; bridging plan; prescriber assuming responsibility and when; OTP transfer status with date/time of next dose window or outpatient buprenorphine follow-up details] (If MOUD declined, document shared decision-making discussion and alternatives offered.)

(If no medications prescribed, state "No medications prescribed at discharge.")

Pending Results

(Omit section if no pending results.)

• Test Pending: [Test name]
  Responsible Reviewer: [Provider/service]
  Patient Notification Plan: [How and by whom]
  Instructions to Receiving Provider: [Follow-up actions if abnormal/time-sensitive]
• (Include infectious disease testing performed or recommended: HIV, hepatitis panel, STI, TB, pregnancy as applicable.)

Discharge Disposition

• Physical Disposition: [home / shelter / recovery residence / higher level facility (name) / other]
• Housing Plan: [Stability status; interim plan if unstable]
• Transportation: [How patient left; how patient will access next appointments]
• Care Coordination: [Records sent; to whom; method; confirmations: warm handoff completed / appointment confirmed]

If AMA/Administrative Discharge: [Patient's stated reasons; risks explained; services offered despite early exit; outreach attempts planned/completed; naloxone and crisis resources provided: yes / no]

Continuing Care Plan

Recommended Level of Care

[Recommended next level: step-down / step-up / maintenance] — [Rationale addressing withdrawal risk; medical needs; mental health; relapse potential; recovery environment; patient preferences/barriers]

Patient Acceptance Status: [accepted / declined / undecided] — [alternatives offered if declined]

Aftercare Services

(Include only domains relevant to this patient.)

• SUD Treatment: [MOUD continuation details; counseling type and frequency; contingency management if applicable]
• Recovery Support: [Peer specialist linkage; mutual support groups (note if medication-friendly needed for MOUD patients)]
• Mental Health: [Psychiatry follow-up; therapy; safety plan monitoring]
• Medical Care: [PCP; infectious disease; prenatal care; pain management; other specialties]
• Harm Reduction: [Naloxone access/refills; safer use education; fentanyl test strips where legal; sterile supplies per local policy]
• Case Management: [Housing; transportation; benefits; employment/education; legal coordination]

Relapse Prevention Plan

• High-Risk Triggers: [People/places/things; internal states]
• Early Warning Signs: [Specific thoughts/behaviors/physical cues]
• Coping Strategies Practiced: [Skills learned and how to use them]
• Support Network: [Who to call 1st/2nd/3rd; contact info if consented]
• Environment Modifications: [Safe storage; avoiding high-risk settings; technology/apps; recovery housing plan]
• Overdose-Specific Plan (if opioid-involved): [Never use alone; naloxone location; call 911; avoid mixing with sedatives; test dose after abstinence]
• If Lapse Occurs: [Non-punitive re-engagement steps; same-day contact number; medication re-initiation plan; post-overdose care pathway]

Follow-Up Schedule

• Appointment 1: [Date/time] or [to be scheduled within X days—responsible party]; [Provider/service name; contact]; [Purpose]; [What patient should bring/do]
• Appointment 2: [Details as above]
• (If not yet scheduled, specify timeframe, who will schedule, identified barriers, and mitigation plan.)

Patient Education and Instructions

• Medication Instructions: [Key changes; how and when to take; side effects to watch for; what to do if dose missed]
• Overdose Recognition & Response: [Signs to recognize; administer naloxone; call 911; rescue breathing per training]
• Warning Signs Requiring Urgent Care: [Worsening withdrawal; chest pain; shortness of breath; severe confusion; suicidal thoughts; allergic reaction]
• Crisis Instructions: [When to call clinic vs. go to ED]; [Program number]; 988; [ED/911]
• Understanding Confirmed: [Teach-back completed: yes / no]; [Caregiver included: yes / no]

(If information for a section is unavailable, document what is missing and why—e.g., "patient left AMA before assessment could be completed"—rather than leaving section blank. Always document suicide risk assessment. When OUD is present, always document overdose risk and naloxone status, even if patient declined.)