Discharge Summary
You must use an actual patient from your clinical experience but remove all identifying information (names, places, etc.) to be Health Insurance Portability and Accountability (HIPPA) compliant.
A Discharge Summary is created when a patient is discharged from an inpatient setting or outpatient program, and the patient’s case is closed. The note is, therefore, a communication between the treating clinician and the next provider or agency involved. Discharge summaries are also written when the patient is deceased.
You may use the format below for your note or the format you use at your clinical site.
EXAMPLE
REASON FOR TRANSFER SUMMARY: This is a transfer summary on XX as the patient will be leaving the x today and will be transitioned to X
DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
DISCHARGE DIAGNOSES: Medical and Psychiatric
REASON FOR ADMISSION:
The patient was admitted with a chief complaint of ____________. The patient was brought to the hospital after his guidance counselor found a note the patient wrote, which detailed to who he was giving away his possessions if he died. The patient told the counselor that he hears voices telling him to hurt himself and others. The patient reports over the last month, these symptoms have exacerbated. The patient had a fight in school recently, which the patient blames on the voices. Three weeks ago, he got pushed into a corner at school and threatened to shoot himself and others with a gun. The patient was suspended for that remark.
PSYCHIATRIC HISTORY:
Keep it brief but significant
PROCEDURES AND TREATMENT:
1. Individual and group psychotherapy. – BE SPECIFIC
2. Psychopharmacologic management. – BE SPECIFIC
3. The social work department conducted family therapy with the patient and the patient’s family for education and discharge planning.
HOSPITAL COURSE:
Brief discussion of hospitalization – how things went. The patient responded well to individual and group psychotherapy, milieu therapy, and medication management. As stated, family therapy was conducted. – HOW DID THESE ALL GO? Discuss all actions taken on behalf of the patient, results (medication trials; responses/ diagnostics, treatments)
DISCHARGE ASSESSMENT:
At discharge, the patient is alert and fully oriented. Mood euthymic. Affect a broad range. He denies any suicidal or homicidal ideation. IQ is at baseline. Memory is intact—insight and judgment are good.
ASSETS and LIABILITIES:
This is strengths/weaknesses/support system/Maslow.
SHORT TERM GOALS and LONG-TERM GOALS:
Determined by staff with patient input, address each goal and progress toward that goal
DISCHARGE PLAN:
The patient may be discharged as he no longer poses a risk of harm to himself or others. The patient will continue the following medications; Ritalin LA 60 mg q a.m., Depakote 500 mg q a.m. and 750 mg q.h.s., Abilify 20 mg q.h.s. Depakote level on the date of discharge was 110. The liver enzymes drawn were within normal limits. The patient will follow up with Dr. Doe for medication management and Dr. Smith for psychotherapy. All other discharge orders per the psychiatrist, as arranged by social work. Any other treatment recommendations
Thank you for receiving this summary.
Signature: current credentials, PMHNP student
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