A therapist recently called me in a panic. She had gotten an audit letter for a client she discharged over 6 months ago. She wanted to know if an insurance company can do an audit on a client she no longer sees.
Yes, they can, and they do.
The instructions in the audit letter were clear. She needed to produce the entire record for the dates requested: the intake summary, treatment plan, progress notes, collateral contact notes, and discharge summary.
She had everything but the discharge summary because she didn’t know how to write one. “Will the insurance company demand repayment without one?” she asked. One would think a discharge summary wouldn’t matter in an audit because they stop paying when treatment is over. But it does. When it comes to audits, we’re legally required to produce what the insurance company wants. Not producing the discharge summary could result in losing thousands of dollars.
The Golden Thread Ends with the Discharge Summary
The discharge summary is the final chapter in the clinical story you and your client have created together. It’s not simply a goodbye note. It’s an inclusive and specific review of treatment that connects directly to the treatment plan, documents why treatment ended, and shows how you prepared your client for life without therapy.
Neglecting to write one may leave you vulnerable to legal issues, licensing board complaints, or insurance denials. Done well, a discharge summary protects you and supports your client’s ongoing journey.
What Belongs in a Discharge Summary
A strong discharge summary answers essential questions:
- What treatment was provided, and how does it reflect the treatment plan?
- What is the client’s condition at discharge?
- What were the reasons for ending treatment?
- What follow-up recommendations were given?
- How was the client notified of discharge?
The content also shifts depending on the type of discharge—whether the client reached the goals, transitioned to another provider, left suddenly, or ended for administrative reasons.
Why It Matters
Insurance Audit Protection
Auditors look for evidence that treatment was goal-directed and concluded responsibly. A discharge summary demonstrates that your work was structured, medically necessary, and time-limited.
Professional Liability Protection
If a client struggles after treatment ends, a detailed discharge summary shows that you ended treatment responsibly, addressed safety issues, and offered follow-up resources.
Licensing Board Defense
Boards want to see ethical and professional closure, including appropriate referrals. A discharge summary documents that process.
Clinical Quality Improvement
Over time, discharge summaries help you identify patterns of success and challenges in your practice, providing valuable feedback for your clinical growth.
How to Write a Discharge Summary That Works
Think of the discharge summary as closing the loop:
- Review treatment provided: Connect goals from the treatment plan with the progress made.
- State the reason for discharge: goals achieved, clinical breach, moved out of state, or another reason?
- Describe the condition at discharge: Clinical status, symptoms managed, skills gained. If the client stopped coming and you don’t know the condition at discharge, document that.
- Include recommendations: Ongoing supports, community resources, or future treatment considerations.
- Confirm notification: Document that the client was informed of the discharge and how informed.
When written this way, a discharge summary becomes more than a formality. It’s a record that protects you and gives your client a clear sense of closure.
Closing the Golden Thread
The discharge summary is the final step in the Golden Thread of documentation. It shows continuity from intake to treatment plan to outcome. Just as important, it protects your license, reduces liability, and ensures your client leaves treatment with clarity about their progress, how to maintain it and how to recognize if a return to therapy is necessary.
Don’t wait until an auditor or an attorney asks, “Where’s your discharge summary?” Write one for every client. It’s your professional safeguard and your client’s bridge to the future.
P.S. Ready to simplify the process? Our Discharge Summary form (included in the Clinical Forms package) prompts you for every essential element so you never have to wonder what to include. Therapists across the country rely on these forms to reduce audit stress and protect their practice.
Ready to simplify the process?
Our Discharge Summary form (included in the Clinical Forms package) prompts you for every essential element so you never have to wonder what to include. Therapists across the country rely on these forms to reduce audit stress and protect their practice.
Strengthen your documentation with proven strategies.
Beth Rontal, LICSW, a private practice therapist and the Documentation Wizard® is a nationally recognized consultant on mental health documentation. Her Misery and Mastery® trainings and accompanying forms are developed to meet strict Medicare requirements. Beth’s Documentation Wizard training program helps clinicians turn their clinical skill and intuition into a systematic review of treatment that helps to pass audits, protect income, maintain professional standards of care, reduce documentation anxiety and increase self-confidence. Beth’s forms have been approved by 2 attorneys, a bioethicist, and a billing expert and have been used all over the world. She mastered her teaching skills with thousands of hours supervising and training both seasoned professionals and interns when supervising at an agency for 11 years. Her newest initiative, Membership Circle, is designed to empower psychotherapists to master documentation with expert guidance, efficient strategies, and a supportive community.
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