Discharge Note Basic Outline

Psychiatric Discharge Note Template

PATIENT NAME:

DATE OF BIRTH:

DATE OF ADMISSION:

DATE OF DISCHARGE:

DATE OF SERVICE:

IDENTIFYING INFORMATION:

ADMISSION LEGAL STATUS:

CHIEF COMPLAINT:

HISTORY OF PRESENT ILLNESS:

PAST PSYCHIATRIC HISTORY:

SUBSTANCE USE HISTORY:

OUTPATIENT MEDICATIONS:

OUTPATIENT PROVIDERS:

PAST MEDICAL HISTORY:

ALLERGIES:

PHYSICAL EXAMINATION:

SOCIAL HISTORY:

FAMILY PSYCHIATRIC HISTORY:

MENTAL STATUS EXAM ON ADMISSION:

HOSPITAL COURSE:

MENTAL STATUS EXAM ON DISCHARGE:

LABORATORY DATA:

DISCHARGE DIAGNOSES:

DISCHARGE PLAN:

MEDICATION CHANGES/ADDITIONS MADE DURING ADMISSION:

MEDICATIONS PRESCRIBED UPON DISCHARGE:

NOTE:  More than 30 minutes was spent by the attending psychiatrist coordinating patient’s discharge from the unit.

Published on 4/13/2020. Copyright 2020 Inpatient Psychiatry Today.