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Addiction Counselor
15-20 minutes

Summary of Discharge for Substance Abuse

The Substance Abuse Discharge Summary template by s10.ai is a vital resource for substance abuse counselors, enabling them to meticulously document a client's treatment progress and discharge strategy. This all-encompassing template features sections for client information, treatment overview, reasons for discharge, and follow-up care instructions, ensuring that crucial details like medications, referrals, and emergency contacts are effectively communicated. Tailored for clinicians in substance abuse treatment centers, this template facilitates a smooth transition for clients advancing to outpatient care or other support services. Designed for integration with s10.ai, an AI medical scribe, it significantly enhances documentation efficiency, encouraging healthcare professionals to adopt and implement this streamlined solution.

2,977 uses
4.5/5.0
J
John Doe
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 at 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 Occupational 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.)
Client 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, +44 123 4567 890
Summary of Treatment:
- Primary Diagnosis: Alcohol Use Disorder, Co-occurring Disorder: Generalized Anxiety Disorder
- Treatment Provided: Individual therapy, Medication-assisted treatment (MAT) with naltrexone, Group therapy sessions
- Client's Response: Significant progress in managing anxiety symptoms, reduced alcohol consumption, occasional challenges with cravings
Reason for Discharge:
- Treatment goals met, client is ready to transition to outpatient care
Discharge Instructions:
- Referrals:
  - Outpatient therapy program at City Health Centre
- Follow-Up Care Plan:
  - Weekly therapy sessions, monthly check-ins with psychiatrist
- Emergency Contacts and Crisis Resources:
  - National Helpline: 0800 123 4567, Local Crisis Centre: 0123 456 789
Medications at Discharge:
- 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:
- Topics Covered: Relapse prevention, coping strategies for anxiety
- Materials Provided: Brochures on harm reduction, 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 and enhance healthcare delivery by incorporating high-search healthcare and clinical keywords. It provides a structured format for capturing essential patient information, including client details, treatment summaries, discharge instructions, and follow-up care plans. Clinicians can efficiently document primary diagnoses, treatment types, and patient responses, ensuring a thorough understanding of each case. The template also facilitates seamless transitions of care by detailing referrals, emergency contacts, and crisis resources. By adopting this template, healthcare professionals can improve patient outcomes, ensure compliance with medical standards, and optimize clinical workflows. Explore this template to enhance your practice's efficiency and patient care quality.
Frequently Asked Questions

Common questions about this template and its usage

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Summary of Discharge for Substance Abuse