Psychiatric Discharge Summary Medical Transcription Sample Report


DATE OF ADMISSION:  MM/DD/YYYY

DATE OF DISCHARGE:  MM/DD/YYYY

DISCHARGE DIAGNOSES:

AXIS I:
1.  Bipolar disorder, depressed, with psychotic features, symptoms in remission.
2.  Attention deficit hyperactivity disorder, symptoms in remission.
AXIS II:  Deferred.
AXIS III:  None.
AXIS IV:  Moderate.
AXIS V:  Global assessment of functioning 65 on discharge.

REASON FOR ADMISSION:  The patient was admitted with a chief complaint of suicidal ideation.  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. 

PROCEDURES AND TREATMENT:

1.  Individual and group psychotherapy.
2.  Psychopharmacologic management.
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:  The patient responded well to individual and group psychotherapy, milieu therapy and medication management.  As stated, family therapy was conducted.

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.

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. 

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