Nursing

With the client you selected in mind, ( Female 44 years old Alcohol and Zanax abuse) address the following in a client termination summary (without violating HIPAA regulations):

Identifying information of client (i.e., hypothetical name, age, etc.)
Date initially contacted therapist, date therapy began, duration of therapy, and date therapy will end
Total number of sessions, including number of missed sessions
Termination planned or unplanned
Presenting problem
Major psychosocial issues
Types of services rendered (i.e., individual, couple/family therapy, group therapy, etc.)
Overview of treatment process
Goal status (goals met, partially met, unmet)
Treatment limitations (if any)
Remaining difficulties and/or concerns
Recommendations
Follow-up plan (if indicated)
Instructions for future contact
Signatures
( will send example to use as a guideline only)