AHC Discharge Summary Form
Patient Name
*
Patient #
*
Date of Birth
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
MR#
*
Admission Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Discharge Date
*
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
CPT Code
Please Select
99239
Other
Patient Unit:
*
Sequoia-100
Pacifica-200
Tahoe-300
Redwood-400
PHP
IOP
IDENTIFYING INFORMATION:
*
0/60
CHIEF COMPLAINT AND REASON FOR ADMISSION:
*
0/550
COURSE OF TREATMENT (To include evaluations, lab/clinical findings, procedures and treatment rendered, treatment goal progress, patient/family response to treatment interventions):
0/675
Acute Medical Conditions:
*
No Acute Medical Conditions. Medically stable without current complaints.
Current acute medical complaints with referrals given. Describe:
Please Type the ACUTE Conditions here
Chronic Medical Conditions on Discharge
*
No Known Chronic Conditions
Current chronic conditions and medically stable without current complaints. Referral given.
Please Type CHRONIC Conditions here:
FUNCTIONAL CONDITION ON DISCHARGE
FUNCTIONAL CONDITION ON DISCHARGE
No deficits. Functions independently
Walking
Independent
Supervision needed
Assistance required
Total Assistance
Fall Risk
Eating
Independent
Supervision needed
Assistance required
Total Assistance
ADL Care
Independent
Supervision needed
Assistance required
Total Assistance
MENTAL STATUS EXAMINATION ON DISCHARGE
General Appearance
Well Groomed
Disheveled
Bizarre
Casual
Appears Stated Age
Appears Older than Stated Age
Appears Younger than Stated Age
Other
Speech / Language
Spontaneous
Slow
Rapid
Slurred
Rambled
Mumbling
Hesitant
Halting
Monotone
Expressive
Mute
Loud
Soft
Other
Attitude/Behavior
Cooperative
Guarded
Irritable
Withdrawn
Indifferent
Other
Mood
Euthymic
Depressed
Euphoric
Anxious
Elated
Irritable
Angry
Fearful
Hopelessness
Other
Affect
Full
Constricted
Irritable
Labile
Expansive
Congruent
Incongruent
Flat
Depressed
Anxious
Euphoric
Blunted
Other
Orientation
Time
Person
Place
Situation
Perception/ Thought Content:
WNL
Hallucinations:
Delusions
Obsessions
Phobias
Other
Hallucinations: (Pick here)
Auditory
Visual
Tactile
Delusions (describe)
Obsessions (describe)
Phobias (describe)
Risk Factors
Suicidal:
Ideations
intent
Plan
Denies
Describe:
Homicidal:
Ideations
lntent
Plan
Denies
Describe:
Thought Processes
Thought Processes:
Concrete
Goal-oriented
Circumstantial
Tangential
Other
Concentration/ Attention Span:
WNL
Impaired
How Tested/Assessed
per observation and interview with the patient
Recent Memory:
WNL
Impaired
How Tested/Assessed
*
3 out of 3 in 3 minutes
0
1
2 out of 3 in 3 minutes
Remote Memory:
WNL
Impaired
How Tested/Assessed
past events as relates the history
Intelligence:
Below Average
Average
Above Average
How Tested/Assessed
based on history
based on vocabulary
based on content
Judgement:
Good
Fair
Poor
How Tested/Assessed
per behavior/history of present illness
Insight:
Good
Fair
Poor
How Tested/Assessed
understanding severity of illness/HPI
PSYCHIATRIC DIAGNOSES ON DISCHARGE
Rows
PSYCHIATRIC DIAGNOSES ON DISCHARGE
MEDICAL DIAGNOSES ON DISCHARGE
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
F31.13 Bipolar Disorder, current episode manic without psychotic features, severe
F31.2 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:
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
F31.13 Bipolar Disorder, current episode manic without psychotic features, severe
F31.2 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:
3
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
F31.13 Bipolar Disorder, current episode manic without psychotic features, severe
F31.2 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:
4
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
F31.13 Bipolar Disorder, current episode manic without psychotic features, severe
F31.2 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:
5
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
F31.13 Bipolar Disorder, current episode manic without psychotic features, severe
F31.2 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:
6
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
F31.13 Bipolar Disorder, current episode manic without psychotic features, severe
F31.2 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:
7
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
F31.13 Bipolar Disorder, current episode manic without psychotic features, severe
F31.2 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:
8
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
F31.13 Bipolar Disorder, current episode manic without psychotic features, severe
F31.2 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:
9
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
F31.13 Bipolar Disorder, current episode manic without psychotic features, severe
F31.2 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:
Other Psych Diagnoses:
DISCHARGE MEDICATIONS: (name, dose, frequency, indication)
Rows
Name
Reason
Dose
Schedule/Frequency
1
2
3
4
5
6
7
NUMBER OF ROUTINELY SCHEDULED ANTIPSYCHOTIC MEDICATION(S) PRESCRIBED:
*
APPROPRIATE JUSTIFICATION FOR DISCHARGING ON TWO OR MORE ANTIPSYCHOTIC MEDICATIONS
3 failed previous medication trials
Cross taper to monotherapy
Augmentation of Clozapine
List the previously failed 3 antipsychotics
*
Cross Titration meds (from what to what):
*
RECOMMENDATIONS/FOLLOW UP/AFTERCARE (To include referrals and appointment dates/times)
*
Attending 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
Pranathi Mruthyunjaya, MD
Dimitri Macris, MD
Aubree Pereyra, MD
Cory Jaques, MD
Christine Le, DO
Kristine Hwang, MD
Mark Laty, MD
Matthew Bryan, DO
Rama Yasaei, MD
Naga Kothapalli, MD
Yujin Lee, MD
Gerardo Perez, DO
Luis Montes de Oca, DO
Gursimran Kehal, DO
Jeri Watson, DO
CLICK HERE AFTER SELECTING ATTENDING NAME
*
Are you a resident?
*
Yes
No
Resident Name:
*
Please Select
Courtney Hsu, MD
Rohini Paul, DO
Adam Ross, MD
Anisa Bravo, MD
Allison Constant, MD
Daniel Bernstein, MD
Resident only:
*
Submit to Provider for final review
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Your Email
*
example@example.com
Resident Signature (Sign your Full Name and Credentials):
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Resident Submit
Provider Signature (Sign your Full Name and Credentials):
I certify that the above note is ready for printing.
*
I agree
Preview PDF
Finalize and Submit
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Date
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Month
-
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2 digit month, 2 digit day, 4 digit year
Date
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AM/PM Option
Provider Email
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Patient Name
Patient #
Patient Name
Patient #
Patient Name
Patient #
MR#
DOB
MR#
DOB
MR#
DOB
Admit Date
Discharge Date
Admit Date
Discharge Date
Admit Date
Discharge Date
Resident Attestation
Provider Attestation for Resident:
Provider Attestation for Scribe Template
Resident Attestation: I have examined the patient and confirmed the essential components of the history, physical examination, diagnosis, and treatment plan. I agree with the patient's care as documented by the resident and amended herein by me. See resident's note for complete details of service. I was present for the key/critical components of the procedures performed by the resident.
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
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