SUD discharge summary and discharge plan: what to include, with a sample

The discharge timeline

For a licensed Texas chemical dependency treatment facility, 26 TAC §564.805 sets the sequence. Discharge planning starts on the first plan, which has to name individualized discharge criteria and initial discharge plans (§564.804(c)).

A step-down (PHP to IOP, IOP to OP) within your program isn't a discharge from care; it's a level-of-care change, with a QCC-signed decision, a revised plan and coordination (§564.804(k)). The continued-stay documentation guide covers writing that step-down plan.

The discharge plan

The counselor and the client (and the consenter, for a minor) develop it together, with family or another support system involved when appropriate (§564.805(a), (d)). The written plan includes:

• Individual goals or activities to sustain recovery, in the client's words: "Go to two meetings a week and call my sister on Sundays."
• Referrals: the next level of care or provider, with name, date and time of the first appointment if you have it; the prescriber who continues any medication; primary care.
• Recovery maintenance services, if any: alumni groups, community meetings, recovery coaching, sober housing.

The completed plan is dated and signed by the counselor, the client and the consenter if applicable; the client and consenter get a copy, and the original signed plan goes in the record (§564.805(f)–(h)). We add three practical lines every client asks about later: who to call if they start using again, the crisis line, and how to come back.

Handing off to the next provider

When you refer or transfer a client for continuing care, Texas expects you to contact the receiving program before discharge, document the coordination (including how soon the client can get in and any constraints on the referral), and, with proper consent, send the relevant records (§564.805(c)).

• Call, then write it down: who you spoke to, the date, the first appointment or how soon the client can be seen, and anything limiting it (waitlist, insurance, transportation).
• Consent first. Substance use disorder records are protected by federal law, and sending them to the next provider needs a written consent that meets 42 CFR §2.31, unless another exception applies. Check that the consent names the receiving provider and hasn't expired.
• Send what they need: the discharge summary, the current plan, the medication list, recent screening scores, and the last ASAM ratings.
• Insurance: the next level may need its own authorization; the prior authorization guide covers who asks for it.

The discharge summary

Within 30 days of discharge, a QCC signs a summary that includes all six of these (§564.805(i)):

1. dates of admission and discharge;
2. the client's needs and problems identified at admission, during treatment and at discharge;
3. the services provided;
4. an assessment of progress toward the treatment goals;
5. the reason for discharge; and
6. referrals and recommendations, including arrangements for recovery maintenance.

Write the summary from the chart, not memory: the plan and its reviews, the screening scores, attendance, and the last treatment plan review. If the summary is signed after day 30, it's late; label it a late entry with the real date (see late entry progress notes).

Unplanned discharges

Clients stop coming, leave against advice, or move. The rule doesn't carve out an exception for a plan the client never signs, so document what you did:

• Outreach: the dates you called, texted or wrote, and what happened. Use only contact methods the client agreed to.
• The discharge date and reason, decided by your policy (for example, after a set number of days without contact) and applied the same way to everyone.
• A discharge plan anyway: referrals and recovery resources, mailed or messaged if the client agreed to that, with a note that the client wasn't available to sign.
• The summary within 30 days and the 60–90 day follow-up attempt, same as a planned discharge.
• Not because of medication. Texas rules bar discharging a client because they take prescribed medication, including medication for opioid use disorder (§564.901(h)).

The 60–90 day follow-up

Contact the client no sooner than 60 and no later than 90 days after discharge, and document their current status or why the contact didn't happen (§564.805(j)). A follow-up at day 45 doesn't count; neither does one at day 100. Put the window on a calendar at discharge, with an owner. Record: the date, the method, who you reached, use since discharge (as the client reports it), whether they're connected to the referral, and any new needs.

A sample discharge summary

Made up. Client A from our continued-stay example, finishing OP.

Discharge in Cima

Cima's discharge summary is on every plan, including Cima for IOP and PHP programs:

• Required fields: the reason for discharge (goals met, client chose to stop, stopped attending, referred to a higher level of care, moved, or other), the course of treatment (at least 15 words), status at discharge, and recommendations and referrals. Put the admission and discharge dates and the services provided in the course, as in the sample above.
• The chart has the evidence: the treatment plan, signed group entries with each client's goal, attendance hours, and PHQ-9 and GAD-7 scores over time, so the summary is written from the record.
• Signed with a PIN and locked. Changes after signing are addenda, with their own author and date.
• Step-downs stay on one chart. PHP, IOP and OP are levels of care on the same chart, so a step-down isn't a discharge and the history stays together.

The 60–90 day follow-up isn't scheduled by Cima today; put it on the calendar as an appointment when you discharge.

Need the discharge policy and forms written for your program? Cima Consulting's IOP / PHP Program Launch includes the policy manual and clinical forms, and a chart audit ($750 per 10 charts) checks closed charts too. For your own quarterly review, Comply's chart audit checklist includes the discharge line.

Questions

Sources

1. 26 Texas Administrative Code §564.805, discharge (as of October 2026). law.cornell.edu
2. 26 TAC §564.804(c), (d), (k), discharge criteria, projected length of stay and level-of-care changes. law.cornell.edu
3. 26 TAC §564.901(h), no denial of admission or discharge because of prescribed medication. law.cornell.edu
4. 42 CFR §2.31, consent requirements for disclosing substance use disorder records. ecfr.gov
5. HHSC, chemical dependency treatment facilities (current rules and guidance). hhs.texas.gov

General information, not clinical or legal advice. Have your attorney confirm your consent forms.