Discharge notes summarize the entire course of treatment, document outcomes, and provide recommendations for continued care. These examples demonstrate how to write thorough discharge summaries across different clinical scenarios, from successful treatment completion to referrals and client-initiated endings.
Part of our therapy notes examples guide.
Therapists completing treatment and closing client charts
Clinicians discharging clients from treatment programs
Providers documenting continuity-of-care transitions
New therapists learning discharge documentation standards
Client Summary
Adult client referred for treatment of generalized anxiety disorder (GAD). Client presented with excessive worry, sleep disturbance, and difficulty concentrating at work. No prior psychiatric hospitalizations. No history of substance use.
Treatment Summary
Client completed 12 sessions of Cognitive Behavioral Therapy (CBT) over 4 months. Treatment focused on cognitive restructuring, worry management, and behavioral activation. Client demonstrated consistent engagement and completed all between-session assignments.
Outcomes
GAD-7 score decreased from 16 (severe) at intake to 5 (mild) at discharge. Client reported improved sleep quality, reduced worry frequency, and restored occupational functioning. Treatment goals were fully met.
Discharge Reason
Mutual agreement between client and therapist. Client met all treatment goals and demonstrated sustained symptom reduction over the final three sessions.
Recommendations
Continue practicing cognitive restructuring techniques independently. Monitor for symptom recurrence, particularly during high-stress periods. Client encouraged to return to therapy if GAD-7 scores exceed 10 or if symptoms interfere with daily functioning. No referrals needed at this time.
Client Summary
Adult client presenting with Major Depressive Disorder, recurrent, severe (F33.2) and Alcohol Use Disorder, moderate (F10.20). Client was referred by primary care physician for outpatient therapy. History includes two prior depressive episodes and escalating alcohol use over the past 18 months.
Treatment Summary
Client attended 8 of 12 scheduled sessions over 3 months. Treatment modality was integrated CBT with motivational interviewing. Sessions focused on behavioral activation, identifying triggers for alcohol use, and developing coping strategies. Client engagement was inconsistent, with three no-shows in the final month of treatment.
Outcomes
PHQ-9 score increased from 18 (moderately severe) at intake to 21 (severe) at discharge, indicating symptom worsening despite treatment. AUDIT score: 24, indicating high-risk alcohol use with no significant reduction during treatment. Client reported continued daily alcohol consumption (4-6 drinks per day) and increasing social isolation. Behavioral activation targets were not consistently met.
Discharge Reason
Clinical determination that client requires a higher level of care. Current outpatient treatment is insufficient to address co-occurring depression and alcohol use disorder given symptom severity and functional decline.
Recommendations
Referral placed to Intensive Outpatient Program (IOP) at Regional Behavioral Health Center for co-occurring disorders treatment. Coordination initiated with prescribing psychiatrist Dr. Martinez regarding medication evaluation for depression. Client provided with crisis resources including 988 Suicide and Crisis Lifeline and local crisis center contact information. Recommended follow-up with PCP for medical evaluation related to alcohol use. Client consented to release of records to IOP and psychiatrist.
Client Summary
Adult client with Complex Posttraumatic Stress Disorder (Complex PTSD) related to prolonged childhood abuse. Comorbid diagnoses include Major Depressive Disorder, recurrent, moderate (F33.1) and Dissociative Disorder NOS (F44.9). Client has extensive trauma history with multiple prior treatment episodes.
Treatment Summary
Client completed 18 of an anticipated 30+ sessions over 7 months. Treatment modality was Cognitive Processing Therapy (CPT) with phase-oriented trauma treatment approach. Stabilization phase was completed successfully. Client began formal trauma processing and completed 2 of 5 identified stuck points before terminating treatment. Client also engaged in grounding skills training, affect regulation work, and psychoeducation regarding dissociation.
Outcomes
PHQ-9 decreased from 16 (moderately severe) to 9 (mild), indicating meaningful improvement in depressive symptoms. PCL-5 decreased from 48 to 32, moving below the clinical threshold of 33, suggesting significant reduction in PTSD symptom severity. DES-II decreased from 22 to 12, indicating reduced dissociative experiences. Client reported improved daily functioning, better sleep, and reduced hypervigilance. However, trauma processing remains incomplete with 3 of 5 stuck points unaddressed.
Discharge Reason
Client-initiated termination due to financial constraints. Client lost insurance coverage and is unable to afford out-of-pocket session fees. Client expressed desire to continue treatment when financial situation stabilizes.
Recommendations
Provided three referrals to sliding-scale trauma-specialized therapists in the area. Recommended client continue CPT when able, beginning with stuck point 3 (self-blame). Relapse prevention plan reviewed: maintain daily grounding practice, use containment visualization for intrusive memories, and contact crisis services if dissociative episodes increase in frequency or duration. Open-door policy communicated — client may return to treatment at any time without re-referral. Records available for transfer to new provider upon client request. Crisis resources reviewed including 988 Lifeline and local crisis stabilization unit.
Discharge notes serve as the final clinical record of a client's treatment episode. They are essential for documenting outcomes, supporting continuity of care, and meeting regulatory and insurance requirements.
Completing a planned course of treatment with goals met
Closing charts and formally ending a treatment episode
Stepping down to a lower level of care (e.g., from weekly to monthly check-ins)
Referring a client to a higher level of care (e.g., IOP, residential)
Treating therapists completing treatment and closing cases
Program directors overseeing client transitions and outcomes
Care coordinators managing referrals and continuity of care
Insurance reviewers evaluating treatment outcomes and medical necessity
Summarizes the entire treatment course with measurable outcomes for the clinical record
Documents clinical reasoning for the discharge decision
Ensures continuity of care by providing clear recommendations for the next provider
Satisfies insurance, regulatory, and accreditation documentation requirements
Client completed 12 sessions CBT for GAD. GAD-7: 16 at intake, 4 at discharge. Treatment goals met. Client using coping strategies independently. No ongoing therapy needed. Relapse prevention plan provided. Return if symptoms recur.
Client attended 16 sessions of individual CBT for MDD over 5 months. PHQ-9 decreased from 19 (moderately severe) at intake to 7 (mild) at discharge. Behavioral activation targets consistently met for final 6 weeks. Client resumed exercise routine, social activities, and full work schedule. Cognitive restructuring skills well-established — client independently challenges depressive automatic thoughts. Sleep improved to 7 hours nightly. Medication maintained (sertraline 100mg, managed by Dr. Patel). Relapse prevention plan completed including warning signs, coping strategies, and support contacts. Step-down to monthly check-ins for 3 months, then discharge from services.
See how discharge notes compare with other common therapy documentation formats.
| Format | Best For | Key Sections | Pros |
|---|---|---|---|
| Discharge Notes | Completing treatment, closing charts, care transitions | Treatment summary, outcomes, discharge reason, recommendations, referrals | Comprehensive treatment record; supports continuity of care; documents measurable outcomes |
| SOAP Notes | Ongoing session documentation, medical settings | Subjective, Objective, Assessment, Plan | Structured and familiar; widely accepted by insurers; easy to review |
| DAP Notes | Session documentation with clinical interpretation | Data, Assessment, Plan | Simpler structure; focuses on clinical reasoning; efficient for experienced clinicians |
| Progress Notes | Tracking treatment progress over time | Session focus, interventions, response, plan | Flexible format; tracks change across sessions; adaptable to any modality |
Follow these best practices to write discharge notes that are clinically thorough, legally defensible, and useful for continuity of care.
Provide a thorough summary — include diagnosis, treatment modality, number of sessions, and goals addressed throughout the course of treatment
Use clinical language with outcomes — document measurable results using pre- and post-treatment assessment scores to support clinical conclusions
Include pre/post assessment scores — compare intake and discharge scores on standardized measures (e.g., PHQ-9, GAD-7, PCL-5) to quantify treatment progress
Write clear recommendations — specify referrals, relapse prevention strategies, and conditions for returning to treatment so the next provider can continue care seamlessly
Missing outcome data
Failing to include pre- and post-treatment assessment scores or measurable outcomes. Discharge notes should clearly document the client's clinical trajectory with objective data points to support the discharge decision.
Incomplete referral information
Noting that a referral was made without specifying the provider, program, or level of care. Discharge notes should include the name of the referral destination, type of treatment recommended, and whether the client consented to the transfer of records.
No relapse prevention plan
Discharging a client without documenting strategies for maintaining treatment gains. Every discharge note should include coping skills reviewed, warning signs to monitor, and steps for re-engaging in treatment if needed.
Judgmental language about termination
Using pejorative or blaming language when clients leave treatment early or against clinical advice. Document the circumstances objectively (e.g., 'Client elected to discontinue treatment' rather than 'Client refused to continue treatment').
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A therapy discharge note should include a client summary, diagnosis, treatment summary (modality, number of sessions, goals addressed), pre- and post-treatment assessment scores, reason for discharge, clinical outcomes, recommendations for continued care, and any referrals provided.
A discharge note should be written when a client completes treatment, is referred to a higher level of care, terminates therapy (whether planned or unplanned), or is being transferred to another provider. It should be completed as close to the final session as possible.
While often used interchangeably, discharge notes typically refer to formal completion or exit from a treatment program and focus on summarizing the full course of care. Termination notes focus more specifically on the ending of the therapeutic relationship and may address the process of ending therapy in greater detail.
Yes, if clinically indicated. Discharge notes should document any ongoing safety concerns, crisis resources provided, and relapse prevention strategies. This is especially important when discharging clients who have a history of suicidal ideation, self-harm, or substance use.
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