When It Is Used
Use it near transition or discharge, when ongoing supports and maintenance needs must remain clear after formal services end.
Transition / Discharge Summary
The Transition / Discharge Summary is a ready-to-complete-together tool for practitioners supporting wraparound discharge. It helps organize current status, continuing supports, risks, responsibilities, maintenance needs, and warning signs into a shared handoff record.
Review the sample summary
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Tool guide
Learn more about this tool
Use this background section to understand when the tool fits, how practitioners use it, and what to consider before sharing it with clients.
Practitioner And Family Roles
The practitioner creates and controls the draft. Client/family and relevant supporters may contribute or confirm information when included in the collaborative workflow.
Relevant Limits
The summary is not a generic care plan, readiness score, eligibility determination, or prediction tool.
Can this be completed with the family?
Yes. The supported mode is ready to complete together, with client/family contribution focused on transition-relevant information.
Does the tool decide whether someone is ready for discharge?
No. It organizes the transition picture and marks missing areas, but it does not produce readiness scoring or clinical predictions.
What happens to unfinished sections?
Unfinished sections remain visible in the draft and review so missing information is not hidden.
Can the summary be updated if transition timing changes?
Yes. The summary remains editable until finalized, and the product should distinguish draft from finalized content.