Discharge Note Template – Inpatient Psychiatry Today

Psychiatric Discharge Note Template

PATIENT NAME:

DATE OF BIRTH:

MEDICAL RECORD #:

DATE OF ADMISSION:

DATE OF DISCHARGE:

IDENTIFYING INFORMATION:

ADMISSION LEGAL STATUS:

CHIEF COMPLAINT:

HISTORY OF PRESENT ILLNESS: (Can copy from admission note, but edit to reflect any new information that was learned during stay)

PAST PSYCHIATRIC HISTORY:

OUTPATIENT MEDICATIONS:

OUTPATIENT PROVIDERS:

SUBSTANCE USE HISTORY:

PAST MEDICAL HISTORY:

ALLERGIES: No known drug allergies.

PHYSICAL EXAMINATION: Hospitalist consulted to perform a standard physical examination upon admission; refer to hospitalist progress note for details.

SOCIAL HISTORY:

FAMILY PSYCHIATRIC HISTORY:

MENTAL STATUS EXAMINATION ON ADMISSION: Patient was alert, oriented, and cooperative. Speech was of normal rate and rhythm. Mood good. Full range of affect. Linear thought process. No delusions. No auditory or visual hallucination. No suicidal or homicidal ideation. Insight and judgment were fair. Alert and oriented x3.

HOSPITAL COURSE:

Medication changes and response
Meetings with informants and relevant information obtained
Was patient cooperative/engaged in discharge planning
Was there disruptive/assaultive/self harming behavior, and were there any restraints?
Were there any significant medical issues or work up during admission?

The patient was admitted on a Section 12 and subsequently signed a conditional voluntary (section 10/11). Medications were evaluated and the patient was started on (or patient was resumed on… or medication X was increased to…) He was medication adherent. Patient gradually improved. No dangerous or disruptive behavior. He attended groups, was visible in the milieu, was social with peers and was cooperative with treatment planning.]

[Initially social isolated, poor ADLs, and refused to engage with the staff and attending psychiatrist, Initially too intrusive and disorganized to attend groups, but eventually improved and was able to participate in group programming. Patient gradually responded well to medications and stabilized psychologically and behaviorally; returned to baseline. The following meetings were held with informants:

MENTAL STATUS ON DISCHARGE:

DISCHARGE DIAGNOSES: (psychiatric and medical, psychiatric first)

MEDICATION CHANGES MADE DURING ADMISSION:

DISCHARGE MEDICATIONS:

DISCHARGE PLAN:

Disposition: where will patient go from hospital and how will he/she get there

Therapy appointment

Psychopharm appointment

PCP appointment

VNA

Case worker

Day treatment

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