You can set up the clinical sections of the Discharge Note to include or exclude specific sections that you may wish to use. In the Discharge or Session Information screen, for the Discharge Note, enter the Provider, Program, and the Discharge Date.
Discharge Status
Click on an option for Discharge Status and for Discharge Condition.
Select a Reason for Discharge from the pick list, or you may type in the filed. For Total Sessions Seen, select an option either Total Sessions or Hospital Days, and then click the Calculate button. Only documented sessions, as well as the Intake will be included in this number. You can override the number by simply typing in the field.
Note: If you have entered an existing client with prior sessions, or have not documented all sessions for a client, add the number of previous or undocumented sessions/hospital days to the calculated number to get your total.
Click on Discharge Recommendations.
Click the down arrow for a pick list. Select a recommendation, and then click the OK button to add it to the recommendations list. Or you can type in the field.
Click the pick list icon 
to edit the list if you have access rights.
Discharge Summary
Click on Discharge Summary to enter your summary in the text field. To spell check, click the icon or select Spell Check from the File menu.
Update information
The following documentation sections can be addressed to update information at discharge:
| • | Enter a Discharge Diagnosis in the DSM-IV Diagnosis section. |
| • | You can record final progress toward goals in the Goals section. Record the date achieved, and mark discharge criteria as having been met. |
| • | You can also enter a percentage of progress toward problem specific goals in the Problems-Objectives section. |
| • | Record risk factors at discharge in the Risks/Strengths section. |
| • | Rate symptoms and impairments at discharge in the Symptoms/Impairments section. |
| • | Record a Mental Status at discharge in the Mental Status section. |
| • | Enter any medications at discharge in the Medications section. |
See Also