Discharge Summary Template

Discharge Summary Template

Client Name: Eliza D

Presenting Problem Upon Admission: [State the client’s presenting problem upon admission. What behaviors would indicate that the client is sustaining at a healthy baseline or the presenting problems are no longer an issue?]

Upon admission, the client presented with excessive worry/anxiety, alcohol dependence, and social phobia/personality disorder. The client presented with client resistance, mood swings/anger, and uncontrolled negative thoughts. Eliza would sustain a healthy baseline if she learns anger management skills, gains structures problem-solving skills, creates a sense of reality, and avoids/stops alcohol abuse.

Current Medication: [List the client’s current medications, if applicable.]

Psychotherapy (i.e., cognitive restructuring, reality therapy, and mindfulness training); exercising/skills training, medication referral, and consultation. Also, Eliza can be treated using drug therapy, i.e., medications. Besides, a combination of both psychotherapy and drug therapy might be used, as all suit Eliza’s case. However, I recommend psychotherapeutic approaches to medication; these should be given top/first priority.

Reason for Discharge: [State the client’s reason for discharge. How did you determine if Eliza met her treatment goals?]

Eliza’s treatment goals were to change unusual behavior and thought patterns, increase the ability to manage anger, establish and maintain alcohol dependence disorder recovery, and to avoid excessive worry. The reason for discharge is because Eliza has positively responded to the treatment. Eliza has acquired a sense of reality, gained structured skills of problem solving, learned positive mood management skills, and learned coping skills. This means her anxiety level has reduced, and her rate of alcohol dependence would cease as time goes on if she continues to practice the learned skills.

Resources and Referrals: [List the client’s resources and referrals. Based on your assessment of current symptomology, does your client, Eliza, need wraparound services, outpatient references, and/or step-down services?]

Projected Prognosis: [State the client’s projected prognosis.]