The discharge summary provides a review of how a patient presented to the hospital, salient psychosocial information and the course of treatment including diagnostic tests and response to interventions. The format will vary between hospitals.
Patient's Name and Medical Record Number: Date of Admission: Date of Discharge:
DSM-IV Multiaxial Discharge Diagnosis Axis I: Clinical disorders
Other conditions that may be a focus of clinical attention. Axis II: Personality disorders Axis III: Medical conditions Axis IV: Psychosocial and environmental problems Axis V: Global assessment of functioning Attending or Ward Team Responsible for Patient: Surgical Procedures, Diagnostic Tests, Invasive Procedures: History of Present Illness: Include salient features surrounding reason for admission, past psychiatric history, social history, mental status exam and physical exam.
Diagnostic Data: Results of laboratory testing, psychological testing, and brain imaging.
Hospital Course: Describe the course of the patient's illness while in the hospital, including evaluation, consultations, medications, outcome of treatment, and unresolved issues at discharge. Address all items on the problem list. Discharged Condition: Describe improvement or deterioration in the patient's condition, and describe present status of the patient.
Disposition: Describe the situation to which the patient will be discharged (home, nursing home), and indicate who will take care of patient. Legal Status at Discharge: Voluntary, involuntary, conservatorship. Discharge Medications: List medications, dosages, quantities dispensed, and instructions.
Discharge Instructions and Follow-up Care: Date of return for follow-up care at clinic; diet, exercise.
Copies: Send copies to attending, clinic, consultants.
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