A Discharge Summary is created when a patient’s case is closed and referred to another provider either by8
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
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 h