Psychiatric Discharge Summary Note

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
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 leadin
the patient’s admission is
incomplete. This includes missi
critical information such as the
reason for transfer or discharge
of admission, date of discharge,
discharge diagnosis
0 pts
Missing
Does not provide psychiatr
history, with missing data
regarding current psychiatr
care or services, provider, a
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
Missing
No clea
descrip
of the
patient’
Hospita
course.
15 pts
Unsatisfactory
Describes a basic
discharge and
treatment plan that
contains errors or is
incorrect for the
primary diagnosis.
0 pts
Missin
No
descrip
of the
dischar
and
treatme
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
Information
unreadable,
multiple mi
in data
organization
unclear
information