Understanding the PLS-5
You and a client just ended services. It can be easy, especially with a busy practice, to simply archive that client in your electronic health record (EHR) and move on without finalizing any documentation, such as discharge summary writing or treatment termination documentation. However, this can be a risk to you and your practice.
Concluding therapy with a discharge summary writing process and termination letter documents the reasons for ending therapy, formally establishes that the client is no longer under your care, supports continuity of care, and provides legal and ethical protection.
Learning how to effectively complete discharge summary writing helps translate these benefits into consistent, defensible clinical practice.
Summary
In this article, you’ll learn how to:
Document therapy termination thoughtfully by clearly recording the rationale for discharge, client progress, and the formal conclusion of care in a way that supports ethical and defensible practice.
Develop comprehensive discharge summaries that include treatment course, outcome measures, referrals, and risk considerations while aligning with commonly recommended documentation standards.
Navigate planned and unplanned termination scenarios by documenting outreach efforts, client communication, and timing considerations to support continuity of care and reduce abandonment risk.
Support care transitions at termination by understanding how to handle referrals, documenting releases of information, and clearly recording follow-up options and next steps for clients.
Treatment termination documentation
When the course of treatment ends, it is time to begin discharge summary writing. It is a clear record of why treatment finished, how it finished, and what is next for the client.
Documenting the lead-up to termination and completing a discharge summary, along with sending a termination letter to the client, are best practices for ending the therapeutic relationship.
Clinicians should also consider when to prepare summary documentation so that timelines support ethical closure and continuity of care.
A summary provides a clear explanation of what happened and signifies a formal end of therapy together. Including thorough treatment termination documentation ensures that if anything happens with the client after this point, there will be a clear demarcation that they are no longer under your care.
What to include in treatment termination documentation
There are several commonly recommended elements to include in discharge summary writing and treatment termination documentation to help protect both client and clinician.
These include:
Date and type of termination: Document whether the termination was planned or unplanned and be very clear on the reasons for ending therapy.
Clinical reasoning for therapist-initiated termination: If you are initiating the termination, document your clinical reasoning clearly to reduce the risk of allegations such as therapist abandonment.
Client communication and outreach attempts: If the client was missing sessions or not communicating, document your attempts to follow up and communicate.
Course of treatment and client progress: Record the treatment provided and summarize client progress, including measurement against treatment plan goals.
Termination discussions: Document any discussions with the client about termination, as well as their acknowledgement and understanding of the termination.
Client mental status and risk level: Note the client’s mental status and any safety or risk considerations as therapy concludes.
Continuation of care plan: If applicable, document referrals or recommendations for continued treatment.
Crisis resources: Record any crisis resources that were shared with the client at termination.
Consultations: Document any consultations you had with a supervisor or colleague regarding the termination.
How to summarize progress
The summary of progress is a key part of discharge summary writing. When considering what to include, center it around the client’s goals in their treatment plan.
It is important to include where the client started from as their baseline. Then, you can use descriptive language and measurements to describe how they met or did not meet those goals.
Examples of clear measurements include assessment scores, average hours of sleep per night, number of panic attacks in a week, etc. These concrete indicators help make a strong case for the progress, or lack of progress, of the client.
It is best practice to avoid using vague statements like “doing much better” or “did not make progress.”
When to prepare discharge summary writing
If the termination is planned and there is a clear, final session, it is recommended to have a discharge summary done within 24 to 48 hours after that session.
If the termination is due to the client dropping out and not communicating, write the summary as soon as possible, while still allowing enough time for outreach to give the client a chance to return to therapy.
Some guides recommend two weeks of no contact from a client as an appropriate amount of time before beginning termination, though there is no hard and fast rule. Clinical judgment plays an important role when determining when to prepare summary documentation, especially in situations involving client dropout or inconsistent communication.
The time window should be long enough to show that you made outreach attempts and didn’t abandon the client. It should not last so long that you are still listed as the client’s provider but are unaware of changes in their life.
Timely completion of the discharge summary writing supports accurate documentation, continuity of care, legal protection through clear termination of services, and compliance with any potential insurance audit requirements.
What about early termination?
If the client ends treatment early, it can be for various reasons: they don’t think it is a good fit, their job or insurance changes, they have an unexpected financial shift, or they simply stop communicating and showing up to sessions. The discharge summary should document these reasons for termination.
If the client has clearly communicated a reason for termination, discharge summaries should be handled promptly, similar to a planned discharge after completing a treatment plan.
If the client stopped communicating, you should document your outreach to them to reduce abandonment risk and demonstrate that you made reasonable attempts to maintain the relationship.
It is recommended that in your practice policies, you inform the clients in advance that if they stop communicating, you will reach out and then discharge them after a specified number of days without communication.
It is also important to document the last known status of the client. Even though the client stopped communicating, sending a termination letter to the client is still best practice to formally end the therapeutic relationship.
How to handle referrals
Understanding how to handle referrals is a critical part of discharge summary writing and ethical treatment termination documentation.
Providing referrals at termination serves two main purposes: to support the client’s continuity of care and to protect yourself from abandonment liability.
When deciding what to include in referral documentation, clearly document the names, contact details, urgency level, and how the referrals were communicated to the client.
Therapists should also document whether a release of information was signed to speak with or provide records to the client’s new clinician. If you have a release, you can send the treatment records to the new clinician.
The referrals can be provided along with a termination letter and any crisis resources or safety plans that might be needed as part of a discharge packet.
A common practice among therapists is to provide three referral options. While ethical codes, such as those of the APA and NASW, do not require a specific number of referrals, they do emphasize providing referrals as appropriate during termination situations.
What about follow-up?
In some situations, it makes sense for termination letters and discussions to include an invitation for a client to restart services in the future. While this may not be applicable in certain termination situations, it is considered a best practice and reduces abandonment risk.
If a client who has been terminated does reach out to restart therapy, use your clinical judgment on whether that is appropriate given your previous history together, their current situation, and if you believe you can help them.
In many situations, once a clear and documented termination has occurred, a therapist’s ongoing duty to the client is limited, though obligations can vary by jurisdiction and circumstance.
There may be rare instances where you learn that a client who is terminated is at high risk, severely struggling, and not following up with care, in which case reaching out to the client may be appropriate and ethical.
As you and your client wrap up therapy and move toward termination, it is important to avoid getting complacent. Best practices require more than just allowing clients to drift out of your practice. Termination is a clinical phase that deserves just as much care and attention as intake or treatment planning.
Ethical practice involves fully supporting the client and documenting all the way to the end of the therapeutic relationship thoughtfully. Implementing these treatment termination documentation practices not only provides the best care for your client but also reduces professional risk that can come along with the termination process.
Disclaimer: This article is intended for educational purposes only and does not constitute legal advice. Laws, regulations, and ethical obligations related to documentation and termination vary by jurisdiction. Clinicians should consult their state licensing board, professional codes of ethics, and legal counsel as needed.
Sources
American Psychological Association. (2017). Ethical Principles of Psychologists and Code of Conduct.
CPH Insurance. Leslie, R. (2022). TERMINATION AND REFERRAL – When Does the Duty to the Patient End?
Documentation Wizard. (2020). Are Discharge Summaries Mandatory?
Innovations in Clinical Neuroscience. McNary, A. L. (2022). Risk management: On the record: Documentation of psychiatric treatment. Innovations in Clinical Neuroscience, 19(7-9), 77–79.
National Association of Social Workers. (n.d.). Social Workers' Ethical Responsibilities to Clients.
PESI. Rontal, B. (n.d.). Meeting Deadlines for Progress Notes in Mental Health.
Social Work Today. Reamer, F. (2006). Terminating Services.
SimplePractice. Caldwell, B. (2025). Therapy termination: How to fire a client.
Social Work Exams. (n.d.). Proper Client Termination in Social Work: Best Practices.
Society for the Advancement of Psychotherapy. (2015). Termination and Abandonment: A Proactive Approach to Ethical Practice.
How SimplePractice streamlines running your practice
SimplePractice is HIPAA-compliant practice management software with everything you need to run your practice built into the platform—from booking and scheduling to insurance and client billing.
If you’ve been considering switching to an EHR system, SimplePractice empowers you to streamline appointment bookings, reminders, and rescheduling and simplify the billing and coding process—so you get more time for the things that matter most to you.
Try SimplePractice free for 30 days. No credit card required.
