DISCHARGE ORDERS
DATE OF DISCHARGE
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Name
*
TYPE OF DISCHARGE
*
Routine
AMA
PSYCHIATRIC DIAGNOSES ON DISCHARGE
Rows
Discharge Medications
Reason
Dose
Schedule
Quantity
Rx Yes
Rx No
1
2
3
4
5
6
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14
BEHAVIORAL HEALTH DISCHARGE DIAGNOSES #1
Please Select
F20.0 Schizophrenia, paranoid type
F23 Brief Psychotic Disorder
F25.0 Schizoaffective Disorder, bipolar type
F25.1 Schizoaffective Disorder, depressed type
F33.2 Major Depressive Disorder, recurrent severe without psychotic features
F33.3 Major Depressive Disorder, recurrent severe with psychotic features
F31.12 Bipolar Disorder, current episode manic without psychotic features, severe
F31.13 Bipolar Disorder, current episode manic with psychotic features, severe
F31.4 Bipolar Disorder, current episode depressed without psychotic features, severe
F31.5 Bipolar Disorder, current episode depressed with psychotic features, severe
F31.63 Bipolar Disorder, current episode mixed without psychotic features, severe
F31.64 Bipolar Disorder, current episode mixed with psychotic features, severe
F31.81 Bipolar II Disorder
F43.11 Post Traumatic Stress Disorder, acute
F41.1 Generalized Anxiety Disorder
F60.3 Borderline Personality Disorder
BEHAVIORAL HEALTH DISCHARGE DIAGNOSES #2
Please Select
F20.0 Schizophrenia, paranoid type
F23 Brief Psychotic Disorder
F25.0 Schizoaffective Disorder, bipolar type
F25.1 Schizoaffective Disorder, depressed type
F33.2 Major Depressive Disorder, recurrent severe without psychotic features
F33.3 Major Depressive Disorder, recurrent severe with psychotic features
F31.12 Bipolar Disorder, current episode manic without psychotic features, severe
F31.13 Bipolar Disorder, current episode manic with psychotic features, severe
F31.4 Bipolar Disorder, current episode depressed without psychotic features, severe
F31.5 Bipolar Disorder, current episode depressed with psychotic features, severe
F31.63 Bipolar Disorder, current episode mixed without psychotic features, severe
F31.64 Bipolar Disorder, current episode mixed with psychotic features, severe
F31.81 Bipolar II Disorder
F43.11 Post Traumatic Stress Disorder, acute
F41.1 Generalized Anxiety Disorder
F60.3 Borderline Personality Disorder
Other Behavioral Health Diagnoses:
PHYSICAL HEALTH DISCHARGE DIAGNOSES
ADDITIONAL DISCHARGE FOLLOW UP RECOMMENDATIONS
Provider Name:
*
Please Select
Michael Serna, MD
Vahig Manugian, DO
Mandeep Bagga, MD
Rahi Daneshvar, MD
Gurpreet Sandhu, MD
Rubby Saini, MD
Setare Eslami, MD
Kingwai Lui, DO
Jaswant Khokhar, MD
Abdolreza Saadabadi, MD
Ninos Adams, MD
Farah Pathan, MD
Toral Desai, MD
Hetal Brahmbhatt, MD
Practitioner Signature
*
Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time
Hour Minutes
AM
PM
AM/PM Option
Email to send completed form to:
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