AI-Assisted Discharge Summary Drafting

This step is critical because 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 (advanced of care, referrals made)
• Discharge reason (planned, AMA, administrative, etc.)

1. Go to claude.ai and log in
2. Click New conversation
3. Paste this context-setting message first:

I'm a substance abuse counselor writing a clinical discharge summary. I'll give you bullet points of clinical facts, and you'll draft a professional discharge summary narrative in the sections: (1) Referral/Admission Information, (2) Course of Treatment, (3) Progress and Response to Treatment, (4) Discharge Status and Medications, (5) Continuing Care Plan and Recommendations.

Write in clinical third person ("The client presented..." not "You"). Length: 400-600 words. Do not include any identifying information. I will add those fields separately.

1. In the next message, type: "Here are the clinical facts for this discharge summary:"
2. Paste your bullet list of deidentified facts
3. Press Enter. Claude drafts the full narrative in 30-60 seconds

What you should see: A 400-600 word discharge summary narrative organized into the five sections you specified.

Read through each section:

• Are the facts accurately represented?
• Does the language sound like your facility's clinical standards?
• Is the continuing care plan section specific and actionable?
• Are there any overstated conclusions or missing nuances?

For any section that needs work: "Revise the 'Progress and Response to Treatment' section to acknowledge that the client showed significant progress on Goal 1 but minimal progress on Goal 2 due to ambivalence about sobriety."

1. Copy the narrative from Claude
2. Open the client's record in your EHR
3. Navigate to the discharge summary form
4. Add identifying fields (name, DOB, record number, dates). These never went into Claude
5. Paste the narrative sections into the appropriate EHR fields
6. Review with your supervisor if required before signing