Discharge Note

When a client's episode of treatment comes to an end, it's important to document that information in the client’s chart using the Discharge Note template. While non-billable, this brief note serves multiple functions, including ensuring the record reflects when you stopped working with a client (reducing liability), the reason for discharge and any clinical recommendations that may support continuity of care, should a client resume services at Rula in the future. Learn more about the steps to discharge a client here

 

Discharge Note Template Fields

The Discharge Note template only contains a few fields and typically takes less than 2 minutes to complete! Follow the below step-by-step instructions below to create a Discharge note in AMD:

  • Open a new Note, Click Note Template Type, then select “Discharge Note”. 
    • Learn more about creating and completing session notes here
  • When the discharge note template pops up, you will notice there is only one tab to complete, with following fields:
    • Date of Discharge: Enter the date where treatment was deemed as complete or terminated. This may be the date of the last session, the date a client reported they will not be returning to therapy, or may simply be the date a therapist has chosen to discharge after a client has disengaged and not responded to outreach. 
    • Discharged from following service: Select the service(s) you have been providing. Some clients may be engaged in multiple services concurrently at Rula with multiple therapists, such as individual and couples therapy, so this field only indicates the service(s) you will no longer be providing them.  
    • Reason for Discharge: There are a variety of options to select from, ranging from client completing treatment goals and terminating successfully, client choice, or simply client did not return to treatment (this option is useful for situations in which outreach and follow up to schedule continued services was made, but client did not respond). 
    • Were the treatment goals achieved? 
    • Other notes (optional): This is an opportunity to add clinical information that is relevant to the discontinuation of care, such as resolution of presenting problem/symptoms, documenting outreach attempts, referrals made for HLOC or rematch, and crisis resources that are available to the client post discharge, if applicable.

Discharge Note FAQ:

  • Does Rula have a policy on when to discharge a client? No, determination of when discharge is clinically indicated is at the discretion of each individual therapist. In the event of client disengagement, a general best practice would be to conduct (and document!) multiple outreach attempts over a few week period to seek re-engagement and offer options for resuming care in the future if desired, prior to discharging. 
  • Why is a discharge note required?  The discharge note signals the end of a therapeutic relationship and summarizes the client’s progress at the end of a treatment episode. It’s important to recognize and document when a therapeutic relationship has ended, regardless of the reason or cause. Unfortunately, a client may terminate the therapy relationship without warning. In those cases, the discharge note acknowledges the abrupt ending and supports your work with the client. The discharge note is also important for facilitating a transition in care for the client and the client’s new treatment team. 
  • Do I need to cancel future appointments? Yes, when you know that you will no longer be providing treatment to a client, you should cancel all future appointments with them. See this article for step-by-step instructions on canceling future appointments from the Rula provider portal.
  • Does writing a Discharge Note automatically remove a client from my caseload? No, writing a Discharge note in AMD does NOT automatically remove the client from your caseload; It simply serves as a record that you are no longer working with the client. The client will be removed from your Client Roster in the Rula provider portal once they have no future appointments booked, and when it has been 90 days since their last appointment with you. If you need to have a client removed from your caseload immediately, please contact Rula support: support@rula.com
  • When I discharge a client from my practice, does it mean they are discharged from Rula too? No, even when a client is removed from your caseload and no longer working with your practice, they are still considered open with Rula and can resume care with you, or another Rula therapist, anytime they wish. 
  • Can I see an example of a completed Discharge Note? You got it! Click HERE

For more information on best practices for discharging a client, check out the Blog Post What therapists should know about ending treatment with clients or reach out to our Clinical quality team at quality@rula.com. Therapist to therapist - we’re here for you!

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