use an actual patient from your clinical experience but remove all identifying information (names, places, etc.) to be Health Insurance Portability and Accountability

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

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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TRANSFER SUMMARY: Discharge Summary for Patient

 

DATE OF ADMISSION: MM/DD/YYYY

 

DATE OF DISCHARGE: MM/DD/YYYY

 

DISCHARGE DIAGNOSES: Psychotic Disorder, Major Depressive Disorder

 

REASON FOR ADMISSION:

The patient was admitted with a chief complaint of escalating suicidal ideation and auditory hallucinations. The patient presented to the emergency department after expressing intent to harm himself and others. He reported experiencing distressing voices commanding him to engage in self-harm and aggression towards others. Additionally, he exhibited symptoms of depression, including low mood, anhedonia, and feelings of hopelessness.

 

PSYCHIATRIC HISTORY:

The patient has a history of recurrent depressive episodes and a previous hospitalization for suicidal ideation. He has been non-compliant with outpatient treatment and has a history of substance use disorder.

 

PROCEDURES AND TREATMENT:

1. Individual psychotherapy sessions focusing on cognitive-behavioral techniques for managing auditory hallucinations and addressing underlying depressive symptoms.
2. Initiation and titration of antipsychotic medication (e.g., risperidone) for the management of psychosis and mood stabilization.
3. Collaborative care meetings involving the patient, psychiatry team, and social work department to develop a comprehensive treatment plan and address psychosocial stressors.
4. Psychoeducation sessions with the patient and family members regarding medication adherence, relapse prevention, and crisis management strategies.

 

HOSPITAL COURSE:

During hospitalization, the patient demonstrated gradual improvement in mood and reduction in suicidal ideation. He actively engaged in therapy sessions and demonstrated insight into the nature of his symptoms. Medication adjustments were made to optimize symptom control while minimizing side effects. The patient participated in milieu therapy activities and displayed appropriate social interactions with peers and staff members.

 

DISCHARGE ASSESSMENT:

At discharge, the patient is alert and oriented to person, place, and time. His mood is euthymic, and affect is appropriate. He denies any current suicidal or homicidal ideation. Cognitive function, including memory and IQ, is within normal limits. Insight into his illness and judgment regarding treatment adherence are satisfactory.

 

ASSETS and LIABILITIES:

Assets: Supportive family members willing to participate in treatment planning and provide a stable living environment. The patient has demonstrated motivation to engage in treatment and develop coping skills.

Liabilities: History of non-compliance with outpatient treatment and substance use disorder. Limited social support outside of immediate family members.

 

SHORT TERM GOALS and LONG-TERM GOALS:

Short-term goals include achieving medication adherence, implementing coping strategies for managing auditory hallucinations, and developing a safety plan for managing suicidal ideation. Long-term goals involve maintaining stability in mood and psychotic symptoms, improving social functioning, and reducing the risk of relapse through ongoing treatment and support.

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