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TRANSFER DISCHARGE SUMMARY

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					TRANSFER/DISCHARGE SUMMARY
Client Name (First, MI, Last) Client No.

Discharge from Agency
Admission Date

Service and/or Program Termination

Transfer

From (Unit/Program/Provider/All Services)

To

Last Contact

Transfer/Termination/Discharge Date

Presenting Problems(s) (Indicate presenting problem at admission and any additional problems addressed during treatment.)

Reason for Transfer/Termination or Discharge (Please check below the appropriate reason for transfer, termination, discharge, or discharge with referral.) Transfer/Termination Increase level of care Decrease level of care Change in type of service Referral (list program(s)/provider client referred to) Discharge Goals met, no services needed Client terminated services Client refused referral for other services Involuntary discharge, client informed of right to appeal Client died Client moved Client did not return Diagnosis: At Admission DSM-IV Code (or successor)
Check Primary

Discharge with Referral Client needed services not available Client referred to AoD Tx Client referred to MH Tx Client referred to MH/AoD Tx

Client referred to MH aftercare Client referred to AoD aftercare Client referred to MH/AoD aftercare Diagnosis: At Transfer/Discharge

ICD-9 CM Codes (or successor) Description

No change in diagnosis
Check Primary

Axis

Code

Axis

Code

Description

Axis I

Axis I

Axis II Axis III Axis IV Axis V Psychosocial/Environmental Problems(s) GAF

Axis II Axis III Axis IV Axis V Psychosocial/Environmental Problems(s) GAF

Indicate Goal(s) Addressed and Progress Made as Written in ISP
Goal 1 Goal 2 Met Met Partially Met Partially Met Not Met Not Met Discontinued Discontinued Overall Progress in Treatment Much Improved Improved Goal 3 Met Partially Met Not Met Discontinued No Change Worse Goal 4 Met Partially Met Not Met Discontinued Goal 5 Met Partially Met Not Met Discontinued

Comments (include progress/gains achieved, client’s strengths and abilities, and current status of client)

SQ-08-170

TRANSFER/DISCHARGE SUMMARY

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Client Name (First, MI, Last) AoD ONLY Adult Level of Care (ODADAS requires completion of Level of Care worksheet) Level I-A: Non-Intensive OP Tx Level II-A: Non-Medical Community Residential Level I-B: IOP Tx Level II-B: Medical Community Residential Level I-C: Day Tx Level III-A: Ambulatory Detox AoD ONLY Youth Level of Care (ODADAS requires completion of Level of Care worksheet) Level I-A: Non-Intensive OP Tx Level I-B: IOP Tx Level II: Residential Level III: Acute Hospital Detoxification

Client No.

Level III-B: 23 Hour Observation Bed Level III-C: Sub-Acute Care Level IV: Acute Hosp. Detoxification Level I-C: Day Tx

Services Provided (check types of services provided during treatment) MH Pharm. Man./Med.-Som. CPST/Case Management Counseling/Therapy Group Counseling/Therapy AoD Partial Hospital/IOP Residential Crisis Services Employment MH AoD Urinalysis Diagnostic Assessment Other: Other: MH AoD

Current Medications (Prescription/OTC/Herbal) at Time of Transfer/Discharge
Medication Dosage Route Oral Inj. Frequency Prescribing Physician

Prescribed by this agency As reported by client

Prescribed by this agency As reported by client

Prescribed by this agency As reported by client

Prescribed by this agency As reported by client Medication reconciliation completed, client given list of all medications (Joint Commission only) Client’s Response to Treatment and Transfer/Termination/Discharge

Continuity of Care/Referral Information (For internal transfer to another program, indicate program/unit, staff receiving case, location, phone no., and/or services to which the client will be transferred. For external referral(s), include agency name, contact name, phone no., location, hours of operation.)

Aftercare Options (include information on symptoms client should watch for, options available if these symptoms recur, or additional services needed.)

Copy of Transfer/Discharge Summary Given to client Mailed to Client Provider Signature/Credentials

If neither, explain: Date Supervisor Signature/Credentials (if applicable) Date

SQ-08-170

TRANSFER/DISCHARGE SUMMARY

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