How to Discharge a Client
Need to document a client leaving your care?
TherapyAppointment does not have a formal discharge process, but allows you the flexibility of how to handle a client discharge. Your practice may have a formal discharge policy. If so, please refer to your own policy for that process.
If your practice does not have a discharge policy, here are some examples of processes that you may wish to consider.
In this Article:
1. There was a conversation with the client
There was a conversation with the client during a session about discharging the patient. Here are some considerations:
You have two options and can use either:
Normal Chart Note
- Document the discharge in your typical progress chart note (charting)
- Move the client to inactive status
- You may also consider toggling their access off to the client portal
Custom Chart Note Template
- Create a custom note template (discharge summary) and use it to document in a chart note (charting)
- Move the client to inactive status
- You may also consider toggling their access to the client portal
2. There was no conversation with the client
There was no conversation with the client during a session, but you have a policy that you discharge clients if they late/cancel or do not show for appointments.
Some practices may fully outline how a client is discharged in their informed consent for no-shows and late cancels. They may also include mailing a letter to the client in order to document that you informed the client you are no longer responsible for their care.
You have two options and can use either:
overview Quick Note Entry
- Write a quick note entry to document that you are discharging the client
- Move the client to inactive status
- You may also consider toggling their access off to the client portal
event Set Appointment for a No Charge Narrative Chart Note
- Create a custom discharge summary note template that indicates the client was discharged due to your policy
- Set a custom CPT code for a discharge service that assigns $0.00 (zero) dollars as the fee and 15 minutes in length
- Put the client on your schedule anywhere you have room, optionally outside your availability
- i.e. early in the day - select the custom CPT code either when scheduling or charting
- Chart on and sign your note (charting → custom templates)
- Move the client to inactive status
- You may also consider toggling their access off to the client portal
Example Narrative Notes
Here are two examples of the narrative that might be involved in a discharge summary.
Example 1:
Notes:
Discharge Summary:
Intake Date:
Discharge Date:
Reason for Admission:
Current Diagnosis: {DIAGNOSIS}
Services Provided:
Living Situation at the time of Discharge:
Patient Strengths:
Patient Needs:
Patient Abilities:
Patient Preferences:
Reason for ending service:
Client's Participation and Progress toward Goals:
Identify how frequently client met, barriers to service delivery, overall participation in services, evaluate each goal and need and progress toward achieving.
If Step-Down, what Services will continue at this time?
Discharge Follow-up Recommendations:
Discharge Summary:
Intake Date:
Discharge Date:
Reason for Admission:
Current Diagnosis: {DIAGNOSIS}
Services Provided:
Living Situation at the time of Discharge:
Patient Strengths:
Patient Needs:
Patient Abilities:
Patient Preferences:
Reason for ending service:
Client's Participation and Progress toward Goals:
Identify how frequently client met, barriers to service delivery, overall participation in services, evaluate each goal and need and progress toward achieving.
If Step-Down, what Services will continue at this time?
Discharge Follow-up Recommendations:
Example 2:
Diagnosis at Discharge:
Reason for Discharge:
Client is being discharged from therapy after an assessment and discussion with client.
This discharge is :
___client initiated
___therapist initiated
___mutually determined
___due to change in insurance
___due to change in finances
___other:
Summary of Treatment:
(Include progress toward goals)
Identified Risk Factors at Discharge:
Three Referrals and Resources shared:
1.
2.
3.
Reason for Discharge:
Client is being discharged from therapy after an assessment and discussion with client.
This discharge is :
___client initiated
___therapist initiated
___mutually determined
___due to change in insurance
___due to change in finances
___other:
Summary of Treatment:
(Include progress toward goals)
Identified Risk Factors at Discharge:
Three Referrals and Resources shared:
1.
2.
3.