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Addiction Counselor
15-20 minutes

Discharge Summary for Substance Abuse

The Substance Abuse Discharge Summary template by s10.ai is a vital resource for substance abuse counselors, designed to meticulously document a client's treatment journey and discharge strategy. This template efficiently captures essential data, including client information, treatment summaries, reasons for discharge, and follow-up care plans, ensuring a thorough overview of the client's progress. It also provides necessary referrals and emergency contacts, alongside sections for medications, legal considerations, and client education. This comprehensive format is invaluable for clinicians in substance abuse treatment environments, facilitating smooth transitions to outpatient care and bolstering ongoing recovery initiatives. Explore the s10.ai template to enhance your clinical documentation and support your clients' recovery pathways.

2,616 uses
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Dr. John Smith
Template Structure

Organized sections for comprehensive clinical documentation

Client Information:
- Name: [Client's full name] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Date of Birth: [Client's date of birth] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Client ID Number: [Client's unique identifier] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Admission Date: [Date of admission to the facility] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Discharge Date: [Date of discharge from the facility] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Primary Contact: [Primary contact or next of kin details] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Treatment Overview:
- [Describe the primary diagnosis and any co-occurring disorders] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Detail the types of treatment provided, such as individual therapy, medication-assisted treatment (MAT), peer support, or group therapy] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Summarize the client's response to treatment, including progress made and any challenges encountered] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Discharge Reason:
- [State the reason for discharge, such as treatment goals met, transfer to another facility, or non-adherence to treatment] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Discharge Guidelines:
- Referrals:
- [List any referrals provided, such as to long-term residential care or outpatient programs] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Follow-Up Care Plan:
- [Describe the follow-up care plan, including recommended appointments, therapy sessions, or ongoing treatment protocols] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Emergency Contacts and Crisis Resources:
- [Provide emergency contacts and crisis resources, including hotlines, local crisis centers, or emergency services] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Medications Upon Discharge:
- [List all prescribed medications, including dosages and instructions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [Indicate any changes to medication regimen made during treatment] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Legal or Work-Related Considerations:
- [Include any legal or occupational information relevant to discharge, such as court-mandated treatment updates or workplace accommodations] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Patient Education:
- [Summarize key educational topics covered during treatment, such as relapse prevention, harm reduction, or coping strategies] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- [List any materials provided to the client, such as brochures, websites, or handouts] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
(Never come up with your own client details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or section blank.)(Use as many bullet points as needed to capture all the relevant information from the transcript.)
Sample Clinical Note

Example of completed documentation using this template

Client Details:
- Name: John Doe
- Date of Birth: 15 March 1985
- Client ID Number: 123456
- Admission Date: 1 September 2024
- Discharge Date: 1 November 2024
- Primary Contact: Jane Doe, Sister, +44 1234 567890
Summary of Treatment:
- Primary Diagnosis: Alcohol Use Disorder, Co-occurring Disorder: Generalized Anxiety Disorder
- Treatment Provided: Individual therapy, Medication-assisted treatment (MAT), Group therapy
- Client's Response: Notable improvement in managing anxiety symptoms, decreased alcohol intake, occasional difficulties with cravings
Reason for Discharge:
- Treatment objectives achieved, client has developed coping mechanisms and is prepared for outpatient care
Discharge Instructions:
- Referrals:
  - Outpatient therapy program at City Health Clinic
- Follow-Up Care Plan:
  - Weekly therapy sessions, monthly check-ins with primary care physician
- Emergency Contacts and Crisis Resources:
  - National Helpline: 0800 123 4567, Local Crisis Center: City Support Services
Medications at Discharge:
- Sertraline 50mg daily, Naltrexone 50mg daily
- No changes to medication regimen during treatment
Legal or Occupational Considerations:
- Court-mandated treatment completed, report submitted to probation officer
Client Education:
- Key Topics: Relapse prevention, harm reduction, stress management
- Materials Provided: Brochures on coping strategies, website links for support groups
Clinical Benefits

Key advantages of using this template in clinical practice

  • This comprehensive clinical template is designed to streamline patient documentation, enhance clinical workflows, and improve patient care outcomes. By integrating high-search healthcare and clinical keywords, this template ensures that clinicians can efficiently document patient details, treatment summaries, discharge instructions, and follow-up care plans. The template is structured to support accurate and thorough record-keeping, facilitating better communication among healthcare teams and ensuring compliance with medical standards. Clinicians are encouraged to adopt this template to optimize their practice, improve patient engagement, and ensure continuity of care. Explore the benefits of implementing this template to enhance your clinical documentation process today.
Frequently Asked Questions

Common questions about this template and its usage

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