Clinical Progress Discharge Summary

The Clinical Progress Discharge Summary is completed by the supervising behavior analyst at the conclusion of ABA services. It records the client’s clinical course and outcomes, including the areas of progress, the status of each targeted maladaptive behavior from intake to discharge, skill acquisition at discharge, caregiver participation, recommendations following discharge, and the overall discharge clinical impression.

This Summary and the Discharge Notification Form (Appendix 24.1) serve different purposes and may be used separately or together. The Discharge Notification Form is the formal notice to the client and caregiver that services are ending, along with the reason for discharge. The Clinical Progress Discharge Summary describes the client’s clinical status and the results achieved during treatment. A clinic whose practice management system already produces a clinical discharge summary may use the Notification Form alone, while a clinic that needs a standalone clinical record may use this Summary. Where a complete discharge packet is required, both are used together.

The behavior and skill tables on the right capture the status of each target. The named rows list common behaviors and skills, and the write-in rows accommodate the individualized target behaviors and skill acquisition or replacement programs specific to the client. The completed Summary is signed by the supervising behavior analyst and filed in the client’s clinical record. [Company] may provide a copy to the caregiver or to a receiving provider upon appropriate request and authorization, consistent with the Discharge and Transition of Services Policy (Appendix 24).