Wellness Program Discharge/Graduation Summary

Participant: [Participant name]; DOB: [DOB]; MRN: [MRN]; Preferred language: [Preferred language]

Program: [Program name]; Start: [Start date]; End/Discharge: [End/discharge date]; Modality: [individual / group]; Format: [in-person / virtual / hybrid]

Disciplines Involved: [List primary team roles involved]

Referring Clinician: [Name], [Role]

Intended Recipient(s): [PCP and/or other clinicians assuming longitudinal ownership]

Author: [Name], [Credentials]; Date: [Date]

Program Disposition

Status: [Graduated (completed program) / Discharged early (non-clinical) / Discharged early (clinical escalation) / Transferred to another program level/pathway] — [planned / unplanned]

Attendance Summary: [One-line attendance summary and curriculum completion status]

Transition Snapshot (For Clinicians)

(Keep concise to fit on approximately one screen. Each metric must include date and source.)

Action Items (time-bound):

• [What] — [By when] — [Responsible party] — [Why]
• (Include 2–5 items as applicable; omit subsection if none.)

Headline Outcomes (baseline → current):

• [Metric]: [Baseline value] ([Date]; [Source]) → [Current value] ([Date]; [Source])
• (Include 2–4 key metrics most relevant to program goals.)

Current Risks Needing Surveillance:

• [Risk factor or concern requiring monitoring]

Follow-up: [Named clinician/team] — [Recommended cadence/timeframe]

Pending Items:

• [Pending test/referral/result] — [Expected timing] — [Who follows up]
• (Include only if items are truly pending; otherwise omit subsection.)

Program Overview

[Referral reason; participant priorities; domains addressed; scope of program vs. what remained with longitudinal clinicians] (One concise paragraph.)

Baseline Risk Profile

(Include dates and sources for all metrics. If critical data are missing and affect safety/interpretation, document "Not assessed" with reason and recommendation.)

Baseline period: [Date or date range]

Cardiometabolic markers:

• Weight/BMI: [Value] ([Date]; [Source]; [Method])
• Blood pressure: [Systolic/Diastolic mmHg] ([Date]; [Source]; [Method/posture])
• Key labs (if in scope): [Lab name: value] ([Date]; [Source])

Lifestyle indicators: (Participant-reported unless stated otherwise.)

• Nutrition pattern: [Brief baseline summary]
• Physical activity: [Baseline frequency/duration/intensity]
• Sleep: [Baseline duration/quality]
• Tobacco/alcohol (if addressed): [Baseline use]
• Stress/coping: [Baseline stressors and strategies]
• (Include only domains relevant to this participant.)

Functional/social factors affecting feasibility: [Relevant limitations or constraints] (Include only if assessed and relevant; otherwise omit.)

Goals and Outcomes

(Present goals with outcomes. Include date and source for all values.)

• [Goal 1 — Domain]:
  • Participant goal: [Goal statement]
  • Baseline: [Value] ([Date]; [Source]) → Current: [Value] ([Date]; [Source])
  • Delta: [Change]; Status: [Achieved / Partially achieved / Not achieved / Deferred / Unable to assess]
• [Goal 2 — Domain]:
  • Participant goal: [Goal statement]
  • Baseline: [Value] ([Date]; [Source]) → Current: [Value] ([Date]; [Source])
  • Delta: [Change]; Status: [Achieved / Partially achieved / Not achieved / Deferred / Unable to assess]
• (Add additional goals as relevant.)

Interpretation: [Brief narrative linking changes to specific metrics or milestones; label patient-reported data; note confounders or concurrent changes; sustainability considerations and remaining gaps] (3–6 sentences.)

Current Status at Discharge

(Include this section when clinical monitoring occurred during the program; otherwise omit or keep minimal with subjective only.)

Subjective: [Current symptoms relevant to program risks, self-efficacy, perceived barriers]

Objective: [Current vitals/anthropometrics and key labs with dates and sources] (Include only if program collected clinical data.)

Safety Concerns: [Active safety issues and recommended escalation steps] (Include only if applicable.)

Ongoing Action Plan

(Organize by domain. Use behaviorally specific language with frequency/duration/intensity. For each domain, include: specific plan, tracking method, key barrier with if–then mitigation strategy, supports/resources, and measurable checkpoint with responsible party. Include only domains relevant to this participant.)

• Nutrition:
  • Plan: [Specific plan with when–where–how]
  • Tracking: [App/log/device]; Barrier + Mitigation: [Barrier] → [If–then strategy]
  • Supports: [Persons, resources]; Checkpoint: [Metric, timeframe, reviewer]
• Physical Activity:
  • Plan: [Aerobic/strength/flexibility specifics with frequency, intensity, time, type]
  • Tracking: [App/log/device]; Barrier + Mitigation: [Barrier] → [If–then strategy]
  • Supports: [Persons, facilities]; Checkpoint: [Metric, timeframe, reviewer]
• Sleep:
  • Plan: [Schedule, routine, environment modifications]
  • Tracking: [Sleep log/device]; Barrier + Mitigation: [Barrier] → [If–then strategy]
  • Supports: [Resources]; Checkpoint: [Metric, timeframe, reviewer]
• Stress Management:
  • Plan: [Technique(s), frequency, context of use]
  • Tracking: [Practice log/app]; Barrier + Mitigation: [Barrier] → [If–then strategy]
  • Supports: [Groups, counseling]; Checkpoint: [Metric, timeframe, reviewer]
• Tobacco/Alcohol (if addressed):
  • Plan: [Abstinence/reduction goals; pharmacotherapy coordination if applicable]
  • Tracking: [Daily log/app]; Barrier + Mitigation: [Trigger] → [Coping strategy]
  • Supports: [Support persons, groups, quitline]; Checkpoint: [Metric, timeframe, reviewer]
• Self-Monitoring:
  • Plan: [What to track and frequency]; Device/Method: [Device/app]
  • Data Sharing: [How/with whom results are shared]; Checkpoint: [Review timing and reviewer]
• (If plan is intentionally minimal, document rationale.)

Relapse Prevention

(Document in patient-friendly language where possible.)

• High-Risk Situations/Triggers: [Participant-specific triggers identified during program]
• Early Warning Signs: [Behavioral, emotional, and situational indicators]
• First-Line Coping Strategies: [Skills and environmental modifications to deploy first]
• Support Escalation Pathway:
  • Self-management: [Immediate actions]
  • Social supports: [Who and how to contact]
  • Program alumni resources: [How to access]
  • PCP/Behavioral health: [When and how to contact]
  • Urgent/Emergency: [Criteria and instructions]
• Re-Entry Criteria: [When to schedule booster sessions or consider re-enrollment]

Resources and Referrals

(Include only if resources or referrals were provided; otherwise omit entire section.)

• [Resource/referral name] — [Category: alumni support / nutrition / activity / behavioral health / social needs] — [Purpose] — [Access instructions] — [Status: referred / scheduled / active / completed / pending] — [Follow-up responsibility]
• (List each resource on a separate line.)

Recommended Follow-up and Monitoring

• Follow-up visits: [Who] — [When/cadence] — [Mode: in-person / virtual]
• Monitoring needs: [Metric] — [Timing and frequency] — [Who orders/reviews] — [Where results route]
• Pending tests/referrals: [Item] — [Expected timing] — [Responsible party] — [Result routing]
• Additional outreach: [Check-in plan, who initiates, when] (Include only if applicable.)