Episode Summary

Admission reason, Dx, treatment dates, modalities, attendance, goals addressed, and outcome measures.

Progress by goal, unresolved needs, medications/providers involved, and client strengths.

Discharge Safety

Complete a C-SSRS / SAFE-T from the patient's current responses when suicidal ideation, self-harm, acute risk, or default risk placeholders are present.

Episode start date:

Episode end date:

Total sessions:

Primary outcome measure:

Baseline / admission value:

Current / discharge value:

Target / review date:

Final / confirmed ICD-10 diagnosis:

Focus	Documentation
Episode outcome	Summarize reason for discharge, diagnoses, goals addressed, progress, and unresolved needs. Reason / outcome: Goals addressed: Remaining needs:
Risk / continuity	Document risk status, safety plan, medications/providers, releases, and handoff details. Risk status: Safety plan status: Handoff / records:
Aftercare	List referrals, follow-up appointments, relapse prevention, crisis resources, and re-entry criteria. Aftercare appointments: Crisis / relapse plan: Re-entry criteria:

Focus

Documentation

Episode outcome

Summarize reason for discharge, diagnoses, goals addressed, progress, and unresolved needs.

Reason / outcome:

Goals addressed:

Remaining needs:

Risk / continuity

Document risk status, safety plan, medications/providers, releases, and handoff details.

Risk status:

Safety plan status:

Handoff / records:

Aftercare

List referrals, follow-up appointments, relapse prevention, crisis resources, and re-entry criteria.

Aftercare appointments:

Crisis / relapse plan:

Re-entry criteria: