Discharge report and final report in psychotherapy: structure

As of October 2026 · about 4 minutes to read

A final report summarises the treatment after it ends: who, when, which method, how many sessions, with what course and outcome. It is brief, substantiated and contains only what the recipient needs. This guide offers a proven structure in eight sections.

What a final report is for

• Closing the treatment documentation: start, end, course and outcome at a glance
• Information for co-treating or follow-up physicians or psychotherapists, if the patient consents
• Proof to payers, when requested
• A look back for the patient, on request

Structure in eight sections

1. Header data: cipher or name (depending on the recipient), treatment period, method, number of sessions, setting.
2. Reason and starting point: in a few sentences, what the patient came with and what was found at the start.
3. Diagnosis or diagnoses: at the start and at the end per ICD-10-GM, if anything changed, with the reason for the change.
4. Course of treatment: what was worked on, with which methods, in which phases; important events with dates.
5. Outcome: achievement of the agreed goals; test scores at the start and the end with instrument and date; what remains.
6. Termination: reason and type (regular, at the patient's request, dropout, interruption, relocation), date of the last session.
7. Further care: your professional notes where useful, for example ongoing co-treatment or agreed follow-up appointments; the decision and wording are yours.
8. Place, date, signature: you sign personally.

Phrase it with evidence

As with every report, concrete dated statements are more reliable than overall impressions. “The PHQ-9 total was 19 at the start and 8 at the end” can be checked; “mood has improved markedly” cannot. For test scores name instrument, value and date, without interpreting them. What was not achieved belongs in as much as what was.

Documentation, retention, access

• Providers must document under § 630f BGB and, as a rule, retain the patient record for ten years after treatment ends; the professional code of your chamber may contain additional rules.
• Patients have a right to inspect their records (§ 630g BGB).
• The report is part of the treatment documentation; file a copy.

Disclosure only with consent

The final report contains specially protected health data and falls under your professional secrecy (§ 203 of the German Criminal Code). Pass it on only if the patient has consented or released you from confidentiality. Write only what the recipient needs for their purpose. A release template is in Letter to the GP or psychiatrist.

Typical mistakes

• Too much detail: the report passes on session content the recipient does not need
• General judgements without evidence
• Test scores without instrument or date
• Disclosure without a release
• Unclear termination: it stays open whether treatment was completed or abandoned

How software can help

Most details are already in your case file: period, session count, scores, notes. The Application Copilot assembles a draft discharge and final report from them, with a source for every sentence. You check, change and sign; you formulate judgements and notes on further care yourself. The sample report on a fictional case shows a substantiated report. To the waitlist.

Frequently asked questions

Is a final report mandatory?

There is no general duty to report to third parties. Documenting the end of treatment is, however, part of the treatment documentation. A report to third parties is provided on request and with the patient's consent.

How long should a final report be?

As short as its purpose allows. For a GP one page is often enough; for your own documentation it may be more detailed.

May the patient inspect the report?

Yes. The right of access under § 630g BGB also covers a final report that is part of the record. Restrictions are possible only for special reasons.