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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 in this article: Completing a discharge note in the Rula provider portal.

 

Discharge Note Template Fields

The Discharge Note template only contains a few fields and typically takes less than 2 minutes to complete! To discharge a client from your caseload, you'll need to submit a discharge note in the provider portal. To do this:

  • Click on the Clients tab in the Provider Portal and Select the client you would like to discharge, Click Note & Documents, then click Add Note, then select “Discharge Note” from the dropdown and Add Note. 
  • 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? No, once a discharge note is completed in the portal, all future appointments with the client will be canceled.
  • Does writing a Discharge Note automatically remove a client from my caseload? Yes, once you have completed the discharge note in the portal, the client will be moved to the "inactive" tab of your client roster.
  • 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. They will however, need to complete a new initial assessment. Please reach out to Rula Support for help scheduling a new assessment for discharged patients you wish to schedule. 
  • Can I see an example of a completed Discharge Note? You got it! Click HERE. 
  • Do I still need to complete an initial assessment for a client that I need to discharge due to an HLOC request? Yes, to be paid for the session you must complete the initial assessment before completing the discharge note.

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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