Discharge Summary Form PDF Details

At the heart of transitioning from treatment to the next phase of recovery is a crucial document known as the Discharge Summary form. This comprehensive form captures the journey of individuals from admission through to their discharge or termination from a treatment program. It immortalizes key data including the client's name, relevant dates such as admission and discharge, initial and concluding diagnoses, and the level of care recommended. A pivotal section asks whether the client has successfully completed the recommended treatment program, alongside the total hours dedicated to the program. Moreover, the form dives into the nature of the discharge—whether the treatment was completed, if there was a withdrawal, or a transfer occurred. It further sheds light on the individual's strengths and abilities, presenting concerns, and primary issues as identified by the American Society of Addiction Medicine (ASAM). Importantly, it evaluates the treatment outcome by examining the client’s attendance, participation, family involvement, adherence to a 12 Step program, and the achievement of treatment goals. The discharge planning process, which is integral for a smooth transition, advisories for referral, and the final discharge diagnosis across diverse axes, are also meticulously documented. Concluding with the essential signatures of both the client and the therapist, this form serves not just as a closure document but as a reflective tool and a roadmap for ongoing recovery and support.

QuestionAnswer
Form NameDischarge Summary Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesou discharge summary, accident discharge medical form, hospital discharge papers pdf, discharge

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Sample

Discharge Summary

Client Name:_________________________________

Date:______________________

Admitting Date:_________________

Discharge/Termination Date:_________________

Admitting Diagnosis: _____________

Discharge/Termination Diagnosis: ____________

Treatment Level Recommended: ___Short Term ___Long Term ___Day Tx ___IOP

The client successfully completed the recommended treatment program: ___ Yes ___ No

Treatment program hours completed: ________

Nature of Discharge: Tx Completed: ____ Withdrew from Tx: ____ Transfer:_______

Client Strengths/Abilities:

Presenting Concerns:

ASAM Primary Issues: 1._______________________________________________________________________

2.______________________________________________________________________

3.______________________________________________________________________

Treatment Outcome (program attendance & participation, family involvement, 12 Step attendance, achievement of treatment goals and expectation):

Updated 2/7/11

______________________________________________________________________________

Discharge Plan:

______________________________________________________________________________

Referrals:

Discharge Diagnosis:

Axis I__________________________

Axis II_________________________

Axis III_______________________

Axis IV________________________

Axis V______

Client Signature:______________________________________ Date:________________

Therapist Signature: ___________________________________ Date:________________

Updated 2/7/11

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Writing segment 1 of online discharge summary

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Part no. 2 of filling out online discharge summary

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Filling out part 3 in online discharge summary

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Discharge Plan Referrals, Discharge Plan Referrals, and Discharge Plan Referrals of online discharge summary

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online discharge summary completion process described (step 5)

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