Guide
Rehab discharge summary: what to include
The document that travels with the client when they leave. Short, specific, and written for the next professional who reads it.
Updated 4 October 2026.
Information, not legal advice. This page is a practical overview for practices. It is not a substitute for advice on your own contracts, insurance or registration.
A discharge summary is the document that travels with a client when they leave a rehab or residential treatment programme. A GP, an outpatient therapist, a community team or a family member with consent may read it. It is often the only part of the record they will ever see. A good one is short, specific and honest about what happened, including when a stay ended early.
This guide sets out what a rehab discharge summary should include, a template you can adapt, and a short fictional example. It is information for treatment centres, not clinical or legal advice. Your clinical lead, your regulator’s guidance and your own policies come first.
Who the summary is for
Write for the next professional, not for the file. The GP needs medication, risk and follow-up. The outpatient therapist needs the formulation, what helped and what is unfinished. The client should be able to read it without being surprised. If a family member will receive a version, that version is an approved report agreed with the client, not the full summary.
What to include
- Identifying details: name, date of birth, admission and discharge dates, programme (residential or outpatient), and the responsible clinician.
- Type of discharge: planned completion, planned early discharge, discharge against advice, or unplanned. Be factual and avoid judgement.
- Reason for admission: the presenting problems in the client’s words and in clinical terms, including substance use and any co-occurring mental health needs that were assessed.
- What was provided: individual and group work, the main approaches used, family sessions if any, and any medical or nursing care.
- Progress against the treatment plan: goal by goal, briefly. Include any outcome measures you actually completed, with dates.
- Risk at discharge: current risk to self and others, risk of relapse and overdose where relevant, and the protective factors you identified. Say what was discussed with the client.
- Medication at discharge: a reconciled list, checked by the prescriber or nurse, with changes made during the stay and the reason for each. Note anything supplied to take home.
- Aftercare plan: appointments already booked, referrals made, support groups discussed, and who is responsible for each step.
- What to do if things go wrong: who the client and family should contact, and local crisis routes. Do not present the treatment centre as an emergency service.
- Consent and distribution: who receives the summary, which version, and the client’s agreement.
- Sign-off: the clinician’s name, role and date.
A template you can adapt
- Client details and dates
- Type of discharge
- Reason for admission
- Assessment summary and formulation
- Treatment provided
- Progress against treatment plan goals
- Outcome measures completed, with dates
- Risk at discharge and safety plan
- Medication at discharge, reconciled
- Aftercare plan and referrals, with owners
- Contacts if things go wrong
- Distribution list and consent
- Signed by, role, date
A fictional example
The person below is invented. No client record was used.
Client: “Sam”, 34. Residential programme, 28 days, planned completion.
Reason for admission: daily alcohol use over two years, escalating after a job loss, with low mood. Referred by their GP.
Treatment provided: individual sessions twice weekly, daily groups, two family sessions with Sam’s partner, and nursing review throughout.
Progress: Sam identified evening isolation as the main trigger and built a written weekday plan. Mood improved over the stay on Sam’s account and in staff observation. Return to work is not yet addressed.
Risk at discharge: no current thoughts of self-harm reported. Relapse risk discussed openly, including reduced tolerance after a period of abstinence. Partner aware of the safety plan, with Sam’s consent.
Medication at discharge: as reconciled by the nursing team on the day of discharge. Copy attached for the GP.
Aftercare: weekly outpatient sessions booked for six weeks. GP appointment booked for the week after discharge. Mutual aid meetings discussed and two local options given.
Unplanned and early discharges
Not every stay ends on the planned day. A client may choose to leave, or a stay may end because of a breach of the programme agreement. These summaries matter more, not less, because the risk is often higher and the aftercare is less settled. Write the summary on the day if you can. Record what was offered, including any aftercare the client declined, and who was told. If the client left without notice, record the steps the team took and when. Keep the tone factual: the reader needs to know what happened and what is in place, not who was at fault.
Timing
Aim to send the summary to the next professional quickly, ideally before the first follow-up appointment. A summary that arrives a month later is history rather than handover. If some sections cannot be completed on the day, send what is ready and say which parts will follow.
Language
Use plain words the client would recognise. Avoid labels that describe the person rather than the behaviour. “Used alcohol daily” is clearer and fairer than a label, and it is what the next clinician needs. Spell out abbreviations the first time. A GP and an outpatient counsellor may use different shorthand from your team.
Common mistakes
- Copying the whole record into the summary. The reader needs the parts that change what they do next.
- Leaving out an early or unplanned discharge. The next service needs to know.
- A medication list that was not reconciled on the day.
- Aftercare steps with no owner and no date.
- Sending the full summary to a family member who should have received an approved report.
Where software helps
When the assessment, treatment plan, notes, nursing records and medication chart live on one record, the summary is assembled from what is already there rather than retyped from memory. In Within, discharge sits on the same client file as the rest of the stay. A secure family report link can share an approved report without opening the clinical record. Discharge feedback can be collected when the client leaves.
Rehab software explains how Reach + Within supports residential and outpatient programmes. Rehabs and treatment centres receive a tailored quote, and there is no public price. The companion guide is the treatment centre admissions checklist.
Related reading
Questions
Is this legal advice?
No. It is information for practices. It is not a substitute for advice on your contracts, insurance or registration.
Are the examples about real clients?
No. Any example in a guide is fictional. Names, ages and details are invented, and no client record was used.
Does the guide apply a retention period for me?
No. Where a source gives a period, the retention guide quotes it. Other guides do not invent a number of years.
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