AI Discharge Summary for Mental Health Counselors Using Opus

DISCHARGE SUMMARY CLIENT INFORMATION: Admission Date: [Date] Discharge Date: [Date] Length of Treatment: 16 sessions over 4 months Type of Discharge: Planned/Mutual agreement - Treatment goals achieved DIAGNOSES AT INTAKE: - Major Depressive Disorder, Recurrent, Moderate (F33.1) - Generalized Anxiety Disorder (F41.1) DIAGNOSES AT DISCHARGE: - Major Depressive Disorder, Recurrent, In Remission (F33.40) - Generalized Anxiety Disorder (F41.1) - Improved/Mild PRESENTING PROBLEMS AT INTAKE: - Severe depressive symptoms (PHQ-9: 18) - Significant anxiety (GAD-7: 14) - Occupational impairment (missing deadlines, difficulty concentrating) - Social isolation (0-1 social activities per month) TREATMENT PROVIDED: - 16 weekly individual psychotherapy sessions (50 minutes each) - Treatment modality: Cognitive Behavioral Therapy - Coordination with psychiatrist for medication management (4 contacts) - Interventions utilized: - Behavioral activation protocol - Cognitive restructuring - Relaxation and mindfulness training - Social engagement planning - Sleep hygiene education PROGRESS AND OUTCOMES: Symptom Measures: - PHQ-9: Decreased from 18 (moderately severe) to 6 (minimal symptoms) - GAD-7: Decreased from 14 (moderate) to 5 (mild anxiety) Functional Improvements: - Returned to full-time work with no missed deadlines in final 8 weeks - Re-engaged with social support system (attending 3+ social activities weekly) - Sleep improved from 4-5 hours to 7-8 hours nightly - Resumed exercise routine (3x weekly) Skills Acquired: - Cognitive restructuring for negative automatic thoughts - Progressive muscle relaxation - Behavioral activation planning - Assertive communication - Sleep hygiene practices DISCHARGE STATUS: Treatment goals achieved. Client demonstrates consistent use of coping skills and maintained symptom improvement for 6+ weeks. AFTERCARE RECOMMENDATIONS: 1. Continue current medication regimen with psychiatrist (Dr. [Name]) - Next appointment: [Date] 2. Monthly therapy "booster" sessions for 3 months, then as needed 3. Continue daily use of learned coping skills 4. Maintain social activities and exercise routine 5. Return to weekly therapy if: - PHQ-9 increases above 10 - Sleep problems return for more than 2 weeks - Significant life stressor occurs 6. Crisis resources provided: 988 Suicide & Crisis Lifeline REFERRALS: - Psychiatry: Continue with current provider - Support group: Referred to local anxiety/depression support group (client considering) PROGNOSIS: Good, given treatment response and skill acquisition Therapist Signature: _________________ Date: _______ Credentials: _________________