Part 1: Using the revised treatment plan completed in Topic 7, complete a discharge summary for your client using the “Discharge Summary” template. This discharge summary should address the following: 1 PAGE
- What behaviors would indicate that the client is sustaining at a healthy baseline?
- How would you determine if Eliza met her treatment goals?
- What factors would determine if the treatment needed to be reevaluated, extended, or possibly referred to another clinician or setting?
- Based on your assessment of current symptomology, does your client, Eliza, need wraparound services, outpatient references, and/or step-down services? (Recommendations should be based on the information gathered for second mandatory evaluation).
- How would you encourage involvement in community-based resources?
Part 2: Write a 700-1,050-word summary statement about your client, Eliza.
Include or address the following in your summary statement:
- Demonstrate whether or not the client met the goals of the treatment plan.
- What specifically contributed to the success of the treatment plan or lack thereof?
- What language would you use to communicate the outcome to the client?
- How would you document the final session?
- Include at least three scholarly references in your paper.
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Topic 8 Discharge Summary Template
Directions: Complete the Discharge Summary form by addressing the fields below.
Presenting Problem Upon Admission:
[State the client’s presenting problem upon admission here.]
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Client Name: [Enter the client’s name here]
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Date of Birth: [MM/DD/YYYY]
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Date of Admission: [MM/DD/YYYY]
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Date of Discharge: [MM/DD/YYYY]
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Current Medication:
[List the client’s current medications here.]
Reason for Discharge:
[State the client’s reason for discharge here.]
Resources and Referrals:
[List the client’s resources and referrals here.]
Projected Prognosis:
[State the client’s projected prognosis here.]
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Eliza D 00/00/00
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<sign and date here>
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Client Signature & Date
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Case Manager Signature & Date
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