WSIB Discharge Summary for Psychology Services

What Is a WSIB Discharge Summary?

A WSIB Discharge Summary is the final clinical document submitted to the Workplace Safety and Insurance Board of Ontario when psychological treatment for an injured worker concludes. It provides a comprehensive account of the treatment episode from assessment through termination, including diagnosis, interventions delivered, outcomes achieved, functional status at discharge, and recommendations for ongoing care or relapse prevention.

The discharge summary closes the treatment loop that began with the initial psychological assessment report. Where the assessment report established the clinical basis for treatment, and progress reports documented the trajectory, the discharge summary provides the definitive account of treatment outcomes. It answers the fundamental question WSIB needs answered: Did the treatment work, and what is the worker's current functional status?

This document has significant implications beyond the immediate treatment episode. WSIB uses the discharge summary to make decisions about the worker's ongoing benefits, return-to-work status, and any future treatment entitlement. If the worker later experiences a recurrence, the discharge summary will be reviewed to determine whether the original treatment was adequate and whether new symptoms represent a new condition or a relapse. In contested claims, the discharge summary may be entered as evidence at the Workplace Safety and Insurance Appeals Tribunal.

For psychologists, the discharge summary also fulfills professional obligations under the College of Psychologists of Ontario standards for record-keeping. It documents that treatment was conducted competently, that outcomes were measured, and that the worker was appropriately transitioned out of care.

When You Need It

A WSIB discharge summary is required when:

• Treatment goals have been achieved — The worker has met the established treatment goals, symptoms have remitted or reduced to a manageable level, and no further treatment is indicated
• Authorized sessions are exhausted — The worker has used all authorized sessions and either WSIB has declined further authorization or no additional sessions are needed
• Worker is non-adherent — The worker has stopped attending sessions, has missed multiple consecutive appointments without explanation, or has formally withdrawn from treatment
• WSIB directs discontinuation — WSIB determines that treatment is no longer authorized, either because the claim has been denied on appeal or because an independent assessment concluded that further treatment is not indicated
• Clinical decision to terminate — You determine that treatment is no longer beneficial, that a different modality or provider is needed, or that treatment has reached a point of diminishing returns
• Worker returns to work — The worker has successfully returned to full duties and treatment goals related to occupational functioning have been met

Key Components and Requirements

Worker and Claim Information: Full name, WSIB claim number, date of injury, employer, date of initial assessment, date of first treatment session, date of final session, and total number of sessions completed.

Diagnosis at Admission and at Discharge: State the initial diagnosis and the diagnosis at discharge. If the diagnosis has changed during treatment, explain the rationale. If the worker no longer meets diagnostic criteria, state this clearly.

Treatment Summary: Provide a concise overview of the treatment delivered, including the therapeutic modality, key interventions, session frequency, and total treatment duration. This is not a session-by-session account but a summary of the treatment arc.

Treatment Goals and Outcomes: List each treatment goal, the baseline status, and the discharge status. Include standardized measure scores at baseline, mid-treatment, and discharge. Calculate and report percentage change.

Functional Status at Discharge: Describe the worker's current functional capacity in daily living, social, and occupational domains. Compare to functional status at the start of treatment.

Return-to-Work Status: State whether the worker has returned to work, the date of return, any accommodations in place, and your clinical opinion on the worker's capacity for sustained employment. If the worker has not returned, explain the barriers and provide recommendations.

Relapse Prevention Plan: Outline the strategies the worker has developed to manage symptoms independently. Include warning signs, coping strategies, and a plan for seeking help if symptoms recur.

Recommendations: Provide any recommendations for ongoing care, including maintenance sessions, referrals to other providers, medication management, or community supports.

How to Write a WSIB Discharge Summary

Step 1: Compile outcome data across the treatment episode. Gather all standardized measure scores from baseline through final session. Create a table showing the trajectory of change for each measure. Calculate percentage improvement and note whether scores crossed clinical thresholds.

Step 2: Review all treatment goals and document final status. Go back to the treatment goals established in your initial assessment report. For each goal, document the baseline status, current status, and whether the goal was achieved, partially achieved, or not achieved. Be honest — partially achieved goals are common and expected.

Step 3: Document functional status comprehensively. Describe the worker's current functioning in daily living, social, and occupational domains. Use the same functional domains you assessed at baseline so that change is apparent. Include the worker's self-report and any collateral information (e.g., employer reports, family physician feedback).

Step 4: Address return-to-work status explicitly. WSIB needs clear information about whether the worker has returned to work, when, in what capacity, and whether accommodations are needed. If the worker has not returned, explain the barriers and provide your professional opinion on prognosis for return.

Step 5: Develop and document a relapse prevention plan. Before the final session, work with the worker to identify warning signs, coping strategies, and an action plan for seeking help. Document this plan in the discharge summary. It demonstrates thorough clinical practice and provides the worker with a concrete tool for maintaining gains.

Step 6: Provide clear recommendations. State whether further treatment is needed. If so, specify the type, rationale, and whether it should be WSIB-funded or community-based. If no further treatment is needed, state this clearly. Include recommendations for other services if applicable.

Step 7: Submit within 10 business days. Complete and submit the discharge summary to the WSIB adjudicator within 10 business days of the final session. Include the claim number on every page. Retain a copy in your clinical file.

Common Mistakes

Omitting standardized outcome data. A discharge summary that says "the client improved" without quantified data is incomplete. WSIB expects pre-and-post comparison scores on standardized measures. Without this data, the discharge summary cannot demonstrate treatment effectiveness.

Failing to compare discharge status to baseline. The discharge summary must show the arc of treatment. Present baseline data alongside discharge data so that the degree of change is clear. A PCL-5 score of 14 at discharge is meaningless without the context that it was 58 at intake.

Not addressing unmet treatment goals. If some goals were not fully achieved, document this honestly with an explanation. Omitting unmet goals makes the report appear incomplete or dishonest. WSIB is more likely to support future treatment requests when the provider has been transparent about outcomes.

Providing a vague relapse prevention plan. A relapse prevention section that says "client will use coping skills" is inadequate. Specify which coping skills, what warning signs to monitor, and what concrete steps the worker should take if symptoms recur.

Neglecting return-to-work details. The discharge summary must clearly state the worker's employment status. If they returned to work, provide the date and capacity. If not, explain why. This information drives WSIB's ongoing decisions about the worker's claim.

Not submitting the discharge summary after non-attendance. Some psychologists neglect to write a discharge summary when a worker stops attending. This is an error. A discharge summary is required regardless of the reason for termination and should document the clinical status at the point of last contact.

Forgetting to address the diagnosis at discharge. State whether the worker still meets diagnostic criteria. If the condition has remitted, say so. If it has changed, explain the change. WSIB uses the discharge diagnosis to inform decisions about ongoing entitlement and future claim management.