How To: Complete a Psychotherapy Termination Note
The Psychotherapy Termination Note is a non-billable note template used to record a client's discharge from treatment. Once a Termination Note is completed and no future appointments are scheduled for the client, the client becomes inactive. Making a client inactive in TherapyNotes removes them from your list of active clients, allowing you to easily view and access the records of the clients you are currently working with.
Once a client has been made inactive, reactivating the client is as easy as scheduling their next appointment. To learn more about discharging clients, read How To: Deactivate or Delete Clients.
To create a Psychotherapy Termination Note:
- Verify that the client has no upcoming appointments
- Click Patients > Patient Name > Documents tab
- Click the Create Note button
- From the list that appears, select Psychotherapy Termination Note
To learn more about creating notes and note writing tools in TherapyNotes, read How To: Create a Note.
The note header automatically fills in information for the client, the client's insurance, the clinician, and the date and time the note was written. To edit information in the note header such as the Note Title or Date & Time, click anywhere on the note header or click Edit in the upper right corner.
Reason for Termination
Click in the Reason for Termination field to select from a list of common reasons for termination, or enter your own reason.
The Chief Complaint includes the primary reason for the client's treatment. The information in this field automatically pulls forward from Presenting Problem field of the client's Psychotherapy Treatment Plan or Intake Note.
Most Recent Diagnosis
The DSM-5 diagnoses, descriptions, and justification for the Most Recent Diagnosis pull forward from the Psychotherapy Treatment Plan, Intake Note, or latest Progress Note for the client. If you need to edit this information, these fields feature searchable DSM-5 diagnoses, allowing you to easily add and edit diagnoses.
Treatment Modality and Interventions
Document the method of treatment and primary interventions used throughout treatment, including the client's response to the interventions used.
Treatment Goals and Outcome
Enter details about the client's progress towards treatment goals and the outcome of treatment. Here, you may also document the client's prognosis.
Sign and Save
Note: In order to save a Psychotherapy Termination Note, you must enter the Reason for Termination, Chief Complaint, and Treatment Goals and Outcome. All other fields are optional.
Once you have completed your Psychotherapy Termination Note for the session, select the Sign this Form checkbox to electronically sign the note and click the Create Note button.
To save an unfinished Termination Note, leave Sign this Form unchecked and click the Save Draft button. You may access your draft later from your To-Do list or click Patients > Patient Name > Documents tab.