Completion of the Discharge Summary is not a claimable service. Document completion in a non-billable note.
Discharge Summary
Client:
InSyst #	Last Name	First Name
Location:	Episode Opening Date:
Agency:	RU:
Services were provided in:	by ☐ interpreter or ☐ clinician
Discharge Summary – Administrative (non-billable)
The provider shall complete a Discharge Summary within 30 calendar days of the last face to face treatment contact for any beneficiary with whom the provider lost contact.
Episode Opening Date:	Episode Closing Date:	Date of Last Face-To-Face:
Discharge Summary Codes - Administrative - Table B
Percent (%) of Tx Plan Goals Achieved	Discharge Status Code
☐ 75 - 50%	4. Left Before Completion with Satisfactory Progress - Not Referred
☐ < 50%	6. Left Before Completion with Unsatisfactory Progress - Not Referred
☐ Death	7. Death
☐ Incarceration	8. Incarceration
Was the client pregnant during treatment? ☐ Yes ☐ No ☐ Unknown
Primary Problem:
Instructions: The counselor/therapist Narrative Summary of the Treatment Episode includes presenting problem, treatment provided and final outcome. The narrative summary must include a reference to the following applicable areas: Current Drug Usage; Legal Issues and/or Criminal Activity; Vocational/Educational Achievements; Living Situation and Referrals.
Counselor/LPHA Narrative Summary of Progress, Treatment, and Reason for Discharge:
Prognosis (select one): ☐ Excellent ☐ Good ☐ Fair ☐ Poor ☐ Guarded ☐ Unstable
Prognosis (Describe rationale for prognosis and further treatment recommendations):
LPHA/Counselor efforts to contact the beneficiary (required):
SUD Counselor/LPHA Signature	Printed Name/Credentials	Date