Psychiatric discharge note
Psychiatric discharge summary note week 3 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 Rubric Psychiatric Discharge Summary Note Psychiatric Discharge Summary Note Criteria This criterion is linked to a Learning OutcomeDischarge Summary This criterion is linked to a Learning OutcomePsychiatric History Ratings 15 pts Proficient Concise documentation on the events leading to the admission. This includes the reason for patient transfer or discharge, date of admission, date of discharge, and the discharge diagnosis. 15 pts Proficient Provides a complete psychiatric history of the patient before the current admission—information including receiving current psychiatric care or services, provider, and treatments such as Psychopharmacology or psychotherapy. 12 pts Acceptable Primarily documentation of events leading to the patient’s admission is present and includes a reason for transfer or discharge, date of admission, date of discharge, and the discharge diagnosis. 12 pts Acceptable Provides the patient’s psychiatric history with information lacking or missing regarding current psychiatric care or services, provider, and treatments such as Psychopharmacology or psychotherapy. 0 pts Missing Documentation of events lead the patient’s admission is incomplete. This includes mis critical information such as th reason for transfer or discharg of admission, date of discharg discharge diagnosis 0 pts Missing Does not provide psychia history, with missing data regarding current psychia care or services, provider treatments such as Psychopharmacology or psychotherapy. Psychiatric Discharge Summary Note Criteria Ratings This criterion is linked to a Learning OutcomeHospital Course 30 pts Proficient Provides a concise description of the patient’s hospitalization and how the admission went. Describe any psychological testing and the patient’s response to treatments, such as Therapy and medications. This criterion is linked to a Learning OutcomeDischarge Assessment and Treatment Plan 30 pts Proficient Describes a detailed discharge plan for patients, including patient follow-ups, treatments such as medications, Therapy, and laboratory orders. 25 pts Acceptable Provides a discussion of the diagnosis with some minor errors or that is not appropriate for the intended recipient. 25 pts Acceptable Describes a detailed discharge and treatment plan for patients, including patient follow-ups, treatments such as medications, Therapy, and laboratory orders. Some details may be vague. 22 pts Needs Improvement The discussion of the Hospital course is vague, missing, or inappropriate data or information present. 22 pts Needs Improvement Describes a general discharge and treatment plan. There are several critical missing details or items irrelevant to the primary diagnosis. 15 pts Unsatisfactory More than one element is vague, missing, or inappropriate for the Hospital Course. 0 pts Missi No cl descri of the patien Hospi cours 15 pts Unsatisfactory Describes a basic discharge and treatment plan that contains errors or is incorrect for the primary diagnosis. 0 pts Missi No descr of the disch and treatm plan. Psychiatric Discharge Summary Note Criteria This criterion is linked to a Learning OutcomeWriting Skills Total Points: 100 PreviousNext Ratings 10 pts Proficient The Discharge Summary Note is well organized, concise, and uses professional terms. 8 pts Acceptable The Discharge Summary note is mainly organized and has 1-2 minor grammar mistakes or information placement. 7 pts Needs Improvement Several mistakes in the placement of information or word choice impact the organization and clarity of the Discharge Summary Note. 5 pts Unsatisfactory Numerous mistakes in wording and placement of information. The Discharge Summary note is disorganized, unprofessional, and challenging to understand. 0 pts Missing Informatio unreadabl multiple m in data organizati unclear informatio
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