Discharge Summary FOR MENTAL HEALTH PATIENT

NURU-645 Various Note Instructions and Rubric

(50 Points – each)

Follow-up Note, Soap Note, Transfer Summary, Discharge Summary

The purpose of these assignments are to allow the student to learn how to do various types of notes that the PMHNP might be called upon to write in the course of their career.  There are many others but here are some of the most common ones we are asked to write. This provides the student with feedback from their instructor as they build towards having the knowledge to write these types of notes when called upon to do so because you will do each type of note twice. This allows the student to concentrate on each different type separately.  You will use a different age group patient for each note.  For Example: If you do a SOAP note on a child then your second SOAP note cannot be on a child, it must be on one of the other 3 age groups. Information needed to complete these notes will be gleaned from a patient interview, chart review and possibly family input.  Try to use a patient that can supply most of the information you need so that you may only need some information from the chart or family. Do not include any identifying data. No names, no locations. These assignments will be submitted as a Word document into the Blackboard assignment links.

Discharge Summary

A Discharge Summary is created when a patient’s case is closed and referred to another provider either by discharge from an inpatient or outpatient program.  It is a communication between the treating clinician and the next person/agency involved. It also occurs if a patient is deceased. The Discharge Summary provides closure. Closures can occur in two ways, written and/or oral. In this assignment, students will produce either a written or an oral discharge summary to assist them in practice when a Discharge Summary is appropriate. A Discharge Summary is a part of the Patient care Documentation (Chart), a legal document and is to be treated as such.

This is a guide for you to use for preparing a Discharge Summary. If your facility uses one you like better, that is fine. Following the information gleaned from a patient interview, a chart review; upload your note or your oral presentation to Blackboard as directed. If you choose a dictated summary it must be verbatim of what would have been written.

This is just an example – Change it to fit your patient

REASON FOR DISCHARGE SUMMARY: This is a discharge summary on XX as patient will be leaving the hospital today and will be followed up in the office of Dr. So-N-SO

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 who he was giving away his possessions to if he dies.  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. 

HISTORY: Keep it brief but significant

PROCEDURES AND TREATMENT:

1. Individual and group psychotherapy. – BE SPECIFIC
   2.  Psychopharmacologic management. – BE SPECIFIC
   3.  Family therapy conducted by social work department with the patient and the patient’s family for the purpose of 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 action taken on behalf of the patient, results (medication trials; responses/ diagnostics, treatments)

DISCHARGE ASSESSMENT:  At the time of discharge, the patient is alert and fully oriented.  Mood euthymic.  Affect broad range.  He denies any suicidal or homicidal ideation.  IQ is at baseline.  Memory intact.  Insight and judgment good.

ASSETS and LIABILITIES:  this is strengths/weaknesses/support system/Mazlow

SHORT TERM GOALS and LONG TERM GOALS: determined by staff with patient input, address each goal and progress toward that goal

DISCHARGE PLAN:  The patient may be discharged as he no longer poses a risk of harm towards himself or others.  The patient will continue on the following medications; Ritalin LA 60 mg q.a.m., Depakote 500 mg q.a.m. and 750 mg q.h.s., Abilify 20 mg q.h.s.  Depakote level on date of discharge was 110.  Liver enzymes drawn were within normal limits.  The patient will follow up with Dr. Doe for medication management and Dr. Smith for psychotherapy.  All other discharge orders per the psychiatrist, as arranged by social work.  Any other treatment recommendations

Thank you for receiving this summary

Signature and Credentials

Rubric