Discharge Summary
SECTION ONE (IDENTIFYING INFORMATION)
Client Name:
Date of Birth:
-
Month
-
Day
Year
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Date of Admission:
-
Month
-
Day
Year
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Date of Discharge:
-
Month
-
Day
Year
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Reason for Discharge:
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Planned Discharge
Asked to leave
Removed by police
Sent to police - did not return
Unknown/Disappeared
Non-compliance
Voluntary departure
Involuntary departure
Death
Time:
Discharge Destination:
-
Hospital
Police jail
Supportive housing
Home
Other
Exit Disposition:
-
Completion without referral
Completion with referral
Suicide
Death
Relocation
Withdrawal
Permission For Follow Up?
Yes
No
Follow Up Scheduled:
-
Month
-
Day
Year
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SECTION TWO (TARGETS)
Basic Summary of Stay: (Please comment on changes in risk factors)
Target (goals) Achieved During Stay:
Targets (goals) Not Achieved During Stay that Will Need Follow-Up:
SECTION THREE (BASIC SUMMARY OF STAY)
Outcomes
Overall Outcomes:
-
Improved
The Same
Decompensated
Staff Perception For Lack of Successful Outcome
Compliance With Care Planning:
-
Attended All
Attended Some
Did Not Attend
Staff Perception For Lack of Successful Outcome
Participation In Care Planning:
-
Active Participation
Some Participation
No Participation
Staff Perception For Lack of Successful Outcome
Medication Compliance:
-
Yes
No
Not Applicable
Staff Perception For Lack of Successful Outcome
Self-care Issues:
None
Some
Subastantial
Staff Perception For Lack of Successful Outcome
Additional Comments:
SECTION FOUR (OTHER SERVICES)
OTHER SERVICES ACCESSED DURING STAY:
REFERRALS MADE DURING STAY:
Should be Empty: