You must use an actual patient from your clinical experience but remove all identifying information

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

You must use an actual patient from your clinical experience but remove all identifying information

 

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 experiencing auditory hallucinations and suicidal ideation. The patient was brought to the hospital after expressing thoughts of self-harm and harming others. He presented with exacerbation of symptoms over the past month, including increased frequency and intensity of auditory hallucinations and suicidal thoughts. Recent incidents at school, including a threat to shoot himself and others, led to suspension.

 

PSYCHIATRIC HISTORY:

 

Brief psychiatric history indicating previous episodes of depression and anxiety. No history of psychiatric hospitalization or suicide attempts.

 

PROCEDURES AND TREATMENT:

 

Individual psychotherapy focusing on cognitive-behavioral techniques to challenge negative thought patterns and enhance coping skills.
Group therapy sessions focusing on psychoeducation, interpersonal skills, and coping strategies.
Psychopharmacologic management with antidepressant medication (SSRI) initiated and titrated under psychiatric supervision.
Family therapy sessions conducted by the social work department to address family dynamics, improve communication, and provide support for discharge planning.

 

HOSPITAL COURSE:

 

During hospitalization, the patient actively engaged in therapy sessions and demonstrated improvement in mood and behavior. He showed good response to individual psychotherapy, reporting decreased frequency and intensity of auditory hallucinations. Group therapy sessions provided opportunities for peer support and skill-building. Medication management resulted in stabilization of mood and reduction in suicidal ideation. Family therapy sessions facilitated communication and addressed family conflicts, enhancing support for the patient’s recovery.

 

DISCHARGE ASSESSMENT:

 

At discharge, the patient is alert, cooperative, and fully oriented. He presents with a euthymic mood and a broad range of affect. The patient denies any current suicidal or homicidal ideation. Cognitive function, including IQ and memory, is within normal limits. Insight into his condition and judgment regarding treatment adherence are considered good.

 

ASSETS and LIABILITIES:

 

Assets: Supportive family environment, motivation for treatment, willingness to engage in therapy, good insight and judgment.

Liabilities: History of depressive symptoms and anxiety, recent exacerbation of psychiatric symptoms, previous school-related incidents.

 

SHORT TERM GOALS and LONG-TERM GOALS:

 

Short-Term Goals:

Develop effective coping strategies to manage auditory hallucinations and intrusive thoughts.
Improve communication skills and conflict resolution within the family.
Enhance social support network and identify community resources for ongoing support.

Long-Term Goals:

Achieve and maintain stability in mood and behavior.
Improve overall functioning in school and social settings.
Develop relapse prevention strategies and continue to engage in supportive therapy as needed.

Psychiatric Discharge Summary Note

Psychiatric Discharge Summary Note

Criteria
Ratings
Pts

This criterion is linked to a Learning OutcomeDischarge Summary

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.

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.

0 pts

Missing

Documentation of events leading to the patient’s admission is incomplete. This includes missing critical information such as the reason for transfer or discharge, date of admission, date of discharge, discharge diagnosis

15 pts

This criterion is linked to a Learning OutcomePsychiatric History

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

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

Does not provide psychiatric history, with missing data regarding current psychiatric care or services, provider, and treatments such as Psychopharmacology or psychotherapy.

15 pts

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.

25 pts

Acceptable

Provides a discussion of the diagnosis with some minor errors or that is not appropriate for the intended recipient.

22 pts

Needs Improvement

The discussion of the Hospital course is vague, missing, or inappropriate data or information present.

15 pts

Unsatisfactory

More than one element is vague, missing, or inappropriate for the Hospital Course.

0 pts

Missing

No clear description of the patient’s Hospital course.

30 pts

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

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

Describes a general discharge and treatment plan.  There are several critical missing details or items irrelevant to the primary diagnosis.

15 pts

Unsatisfactory

Describes a basic discharge and treatment plan that contains errors or is incorrect for the primary diagnosis.

0 pts

Missing

No description of the discharge and treatment plan.

30 pts

This criterion is linked to a Learning OutcomeWriting Skills

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

Information is unreadable, multiple mistakes in data organization, and unclear information.

10 pts

Total Points: 100

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