of 5— Gather your clinical facts before opening Claude

What you'll accomplish

By the end of this guide, you'll have a consistent, efficient process for drafting discharge summaries using Claude — turning a 2–3 hour documentation task into a 45-minute review-and-finalize workflow. You'll also have a reusable discharge summary template you can use for every client discharge going forward.

What you'll need

A Claude account — free tier at claude.ai works well; {{tool:Claude.plan}} subscription at {{tool:Claude.price}} for longer documents and Projects
The client's clinical history gathered in bullet-point form (deidentified — no name or DOB)
Your facility's discharge summary format (if required — most fields translate directly)
Time needed: 30 minutes to build your process; 45 min per discharge thereafter
Important: Never enter client name, DOB, SSN, or record number into any AI chatbot — use deidentified summaries

How-To Guide: AI-Assisted Discharge Summary Drafting

Step 1: Gather your clinical facts before opening Claude

This step is critical — a good discharge summary requires the right inputs. Before opening Claude, collect:

From the client's chart (deidentified):

Primary substance(s), severity, use history
ASAM level of care and length of stay
Co-occurring diagnoses
Treatment goals from the initial treatment plan
Progress on each goal (achieved / partially achieved / ongoing)
Key interventions provided (group modalities, individual counseling topics, MAT if applicable)
Medications at discharge
Any significant events (hospitalizations, positive drug screens, legal changes)
Continuing care plan (next level of care, referrals made)
Discharge reason (planned, AMA, administrative, etc.)

Write these in a bullet list — 15–20 bullets is ideal.

Tools:Claude