Episode Summary

Episode start date:

Episode end date:

Total sessions:

Primary modality:

Presenting problem at admission:

Diagnosis Search

Final / confirmed diagnosis

Coding Details

Status

Select status...

Severity

Select severity...

Onset Date

YYYY-MM-DD

Resolved Date

YYYY-MM-DD

Outcome measure (baseline → discharge):

Reason for Termination

Treatment goals met

Mutual agreement — stable / maintaining gains

Client-initiated termination

Lost to follow-up / No-show

Transferred care to another provider

Insurance / Financial

Moved / Relocation

Additional context:

Goal Progress

Goal #1

Goal:

Status:

Partially met

Not met

Deferred

Notes:

Goal #2

Goal:

Status:

Partially met

Not met

Deferred

Notes:

Remaining needs / Unresolved issues:

Discharge Safety

Discussed warning signs and self-monitoring

Provided crisis resources (988 or local crisis number)

Means-restriction counseling addressed (when SI history present)

Releases of information / records handoff signed

Risk / Safety Review

1. Ideation Level

0 — None 1 — Wish Dead 2 — Nonspecific Thoughts 3 — With Method 4 — With Intent 5 — With Plan

1. Actual Attempt

Self-Injurious Behavior with Intent to Die

2. Interrupted Attempt

3. Aborted/Self-Interrupted Attempt

4. Preparatory Acts or Behaviors

5. Non-Suicidal Self-Injury (NSSI)

Most Recent Behavior

yyyy-mm-dd

Lethality (0-10)

Clinician Risk Override

No Override

Risk status at discharge:

No current risk

Low risk — stable

Moderate risk — safety plan in place

Elevated risk — see safety documentation

Aftercare

Referrals:

Outpatient therapy (new provider)

Psychiatry / Medication management

PCP / Medical

Support group

Crisis line (988 / local)

Case management / Social services

Follow-up appointment:

Relapse prevention plan:

Re-entry criteria:

Plan and Follow-Up

Plan area	Details
Next visit
Orders & referrals
Patient instructions
Monitoring & safety

Episode Summary

Diagnosis Snapshot

Reason for Termination

Goal Progress

Goal #1

Goal #2

Discharge Safety

Risk / Safety Review

C-SSRS

Suicidal Ideation Severity ⓘ

Suicidal behavior (lifetime; most recent date below)

Risk Details

Aftercare

Plan and Follow-Up

Counseling - Termination and Discharge Note

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