Discharge summary and summary statement
Part 1: Using the revised treatment plan completed in Topic 7, complete a discharge summary for your client using the “Discharge Summary” template. This discharge summary should address the following:
- What behaviors would indicate that the client is sustaining at a healthy baseline?
- How would you determine if Eliza met her treatment goals?
- What factors would determine if the treatment needed to be reevaluated, extended, or possibly referred to another clinician or setting?
- Based on your assessment of current symptomology, does your client, Eliza, need wraparound services, outpatient references, and/or step-down services? (Recommendations should be based on the information gathered for second mandatory evaluation).
- How would you encourage involvement in community-based resources?
Part 2: Write a 700-1,050-word summary statement about your client, Eliza.
Include or address the following in your summary statement:
- Demonstrate whether or not the client met the goals of the treatment plan.
- What specifically contributed to the success of the treatment plan or lack thereof?
- What language would you use to communicate the outcome to the client?
- How would you document the final session?
- Include at least three scholarly references in your paper.
Submit your discharge summary and summary statement to your instructor.
Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.
This assignment uses a rubric.
Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
You are required to submit this assignment to LopesWrite. Please refer to the directions in the Student Success Center.
This assignment meets the following CACREP Standard: 2.F.5.k: Strategies to promote client understanding of and access to a variety of community-based resources intervention.
This assignment meets the following NASAC Standards:
73) Conduct continuing care, relapse prevention, and discharge planning with the client and involved significant others.
74) Assure the accurate documentation of case management activities throughout the course of treatment.
75) Apply placement, continued stay, and discharge criteria for each modality on the continuum of care.
112) Prepare and record treatment and continuing care plans that are consistent with agency standards and comply with applicable administrative rules.
114) Prepare an accurate, concise, informative, and current discharge summary
Topic 8 Discharge Summary Template
Directions: Complete the Discharge Summary form by addressing the fields below.
Presenting Problem Upon Admission:
[State the client’s presenting problem upon admission here.]
Client Name: [Enter the client’s name here]
Date of Birth: [MM/DD/YYYY]
Date of Admission: [MM/DD/YYYY]
Date of Discharge: [MM/DD/YYYY]
[List the client’s current medications here.]
Reason for Discharge:
[State the client’s reason for discharge here.]
Resources and Referrals:
[List the client’s resources and referrals here.]
[State the client’s projected prognosis here.]