How To: Complete a Psychiatry Termination Note

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The Psychiatry 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.

Role Required: Clinician, Intern, or Clinical Administrator

To create a Psychiatry 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 Psychiatry Termination Note

To learn more about creating notes and note writing tools in TherapyNotes, read How To: Create a Note.

Note Header

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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.

Quick Tip: If you prefer to use the title Discharge Summary, click anywhere on the note header and enter Discharge Summary in the Note Title field. Click the Update Note Header button when finished.

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.

Chief Complaint

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 Psychiatry Treatment Plan or Intake Note. 

Most Recent Diagnosis

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The DSM-5 diagnoses, descriptions, and justification for the Most Recent Diagnosis pull forward from the Psychiatry 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 Psychiatry Termination Note, you must enter the Reason for Termination, Chief Complaint, and Treatment Goals and Outcome. All other fields are optional.

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Once you have completed your Psychiatry 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.

Have more questions? Submit a request

Comments

  • Avatar
    Terri Schaffner

    Our state regulations require that we provided Discharge Planning and Crisis Planning during the Intake Process; we are not finding these documents in TherapyNotes. All we have found thus far is the Termination Note, which is after the fact.

    Can Therapynotes customize these documents for us to utilize?
    thanks

  • Avatar
    Laura

    Terri,

    Currently the note templates are not customizable in TherapyNotes. You can enter the Discharge Planning and Crisis Planning and information in the "Other Information" field at the bottom of the "Background Information" section.

    Another option is to use the Miscellaneous Note to record that information. To do so, go to the patient's chart and click the "Notes" tab. From the dropdown menu select "Miscellaneous Note". Be sure to select that the note is visible to the assigned clinician only since it contains clinical information. You have the option to check a box in the note template to make the item billable. Please note that Miscellaneous Notes are not billable to insurance. 

    If you have documentation that states that it is required for that information to be in the note in your area, please forward it to support@therapynotes.com so we can look into it further. Thank you!

    Edited by Laura
  • Avatar
    Nancy Smith

    We have a client that we did a termination note and is still showing up active. There is no future appts either. Is there something else that we need to do?

  • Avatar
    Laura

    Nancy,

    One of our support team members will contact you directly about this issue. Thank you.

  • Avatar
    Brad Larsen Sanchez

    How long after the most recent appointment or most recent contact note will TN prompt me to complete a termination note? We need to know this duration for state requirements.

  • Avatar
    Sean Behan

    Hi Brad,

    This is a setting that is customizable in TherapyNotes. Please click User Icon > Settings > To-Do List to customize the length of time between the last contact and a prompt for a termination note. Thank you.

  • Avatar
    Nicole Strong

    What would you suggest to do if a client returns to therapy after doing a termination note? Is a new intake note required?

  • Avatar
    Jordan

    Nicole,

    If after 6 months you should always do a new intake note. You will want to contact the insurance company to see if you are able to bill another 90791. If you have any questions please let contact support at 215-658-4550 or via email at support@therapynotes.com