Record the clinically relevant exchange.
Record who participated and why the consultation took place. Include the information shared and decisions made, with relevant risk content and follow-up.
Course 4 · Case Consults, Summaries & Discharges
Know what to write when care involves more than a session note.
Learn what to include when you document communication between sessions or the end of treatment. Practice writing consult and contact notes, then treatment and discharge summaries.
$37Self-paced course · lifetime access · 30-day guarantee
Reason for dischargeTreatment goals met; planned completion.
Course of careCBT-based outpatient psychotherapy with progress monitoring.
OutcomeGAD-7 decreased from 16 at intake to 4 at discharge.
RiskNo acute safety concerns identified at discharge.
AftercareContinue practiced skills; return if symptoms recur or functioning declines.
Course roleCloses
Is this a good fit?
This training is for…
Therapists who need guidance for documentation outside the regular session note, including the end of treatment.
Study at your own pace in Mini Course Generator. Download the PDFs from Google Drive to use alongside the lessons.
- You're unsure when to use a consult note instead of a contact note.
- You want help deciding what belongs in a treatment summary.
- You need to document discharge, including an unplanned end to care.
- You want clearer documentation of coordination and responsibility for follow-up.
Four document types
Choose the document that matches what happened.
Compare the documentation needed for a consultation, a contact between sessions, a treatment summary, and a discharge.
Account for what happened between sessions.
A contact note captures relevant communication, including brief interventions or safety content, without turning the contact into a session note.
Limit the summary to its purpose.
Use the purpose of the summary to decide what information to include. The course addresses release of information (ROI) and the minimum-necessary standard.
Close the episode of care.
Document the reason for discharge and the treatment outcome in relation to the original goals. Include risk findings and aftercare recommendations.
Route 01Consult
Route 02Contact
Route 03Summary
Route 04Discharge
ConsultPurpose, participants, information exchanged, clinical decision, and follow-up.
ContactCommunication, clinically relevant content, response, and next action.
SummaryPurpose-limited treatment course, response, current status, and recommendations.
DischargeReason, course of care, outcome, risk, aftercare, and Golden Thread review.
The review test
Have you documented the communication and follow-up?
Check that you've recorded the reason for contact and the information shared. Include any decisions about follow-up.
What was the purpose of the contact or summary?
The purpose should be clear enough to guide what information belongs.
What was communicated or decided?
The record accounts for clinically relevant content and follow-up.
What happened across treatment?
The summary and discharge documents connect the outcome to the original need and plan.
Who is responsible for follow-up?
Document the aftercare recommendations and any referrals, including who will take the next action.
Inside the course
You'll learn…
Each lesson includes a format guide and a worked Marcus example. You'll practice drafting the document and compare your response with a model before reviewing it.
Case consult and collateral notes
Record the purpose and participants, including what was shared and any follow-up decisions. Address relevant risk and mandated-report or duty considerations.
Contact notes
Distinguish contact notes from session notes. Document brief interventions and relevant risk information, including what happens next.
Treatment summaries
Consider ROI and the minimum-necessary standard when deciding which treatment details to include in a summary.
Discharge summaries
Summarize the treatment and reason for discharge. Include the outcome and aftercare recommendations, with relevant risk and billing information.
Complex closures
Handle loss to follow-up, discharge against clinical advice, step-up transfer, and high-conflict collateral situations.
Three-document capstone
Apply the method to a consult, treatment summary, and discharge across different clinical cases.
A look at the actual workbook
See what you'll work with.
These are pages from the Closure Documentation Workbook PDF included with this course. Select a page to take a closer look.
Work with it
Handouts included
Use the templates to draft a response to the practice case, then compare it with the completed example.
- Closure Documentation WorkbookWriting prompts and completed examples for all four document types.
- Case Consult templateFor consultation and collateral communication.
- Contact Note templateFor relevant communication between sessions.
- Treatment Summary templateFor a summary written for a specific purpose.
- Discharge Summary templateFor documenting the end of care.
- Closure audit checklistReview your documentation before you finish.
More complex situations
Document an unplanned end to treatment.
Work through examples involving loss to follow-up or discharge against clinical advice. The bonus also covers transfers to a higher level of care and high-conflict collateral situations.
Document the attempts and the final action
Make the no-abandonment steps and disposition understandable from the record.
Document a transfer to a higher level of care
Record the referral and relevant safety information, including communication with the receiving provider.
Document relevant clinical information
Consider ROI and the minimum-necessary standard when documenting the exchange.
Choose what fits
Choose this course or the full series.
Choose this course for documentation between sessions and at discharge. The bundle also covers assessment and treatment planning, along with ongoing session notes.
04→
04→
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Case Consults, Summaries & Discharges · $37
The course, workbook, templates, examples, practice, certificate, lifetime access, and 30-day guarantee.
From Intake to Discharge · $97
All four courses plus the complete Templates and Examples pack.
Templates and Examples · $47
All seven documents with completed models, without the training.
Write it Right: Case Consults, Summaries & Discharges
Get help with consultation and discharge documentation.
Compare your documentation with the examples. Would another clinician know what follow-up was recommended?