Psychiatric Discharge Summary Document #14
Date of Admisson:
Date of Discharge:
Noncompliance with Treatment
Chronic mental illness
No Social Supports
Limited Social Supports
Problems with primary support group
Problems related to the social environment
Housing problems/Economic problems
Problems with access to health care services
Problems related to interaction with the legal system
Other psychosocial and environmental problems explained
Poor Coping Skills
Axis V: (Current GAF SCORE)
Hospitalist or Specialists
REASON FOR ADMISSION:
Crisis Evaluation/Include Last Psychiatric Admisson
PROCEDURES AND TREATMENT:
1. Individual and group psychotherapy. 2. Psychopharmacologic management. 3. Family therapy conducted by treatment team with the patient and the patient's family for the purpose of education and discharge planning.
Pertinent Laboratory Data: Urine Drug Screen: Negative Metabolic Panel: Within Normal limits Thyroid Studies: Within Normal limits Lipid Panel: Within Normal limits Special Medication Levels: NONE Imaging or other tests Performed: NONE
The patient responded well to individual and group psychotherapy, milieu therapy and medication management. As stated, family therapy was conducted.
DIAGNOSTIC IMPRESSION OF CASE:
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. Diagnostic impression and proposed treatment plans were reviewed with the patient. No imminent danger to self or others was assessed. Patient is willing to seek help on outpatient basis. Patient has no current suicidal ideation or plans. No homicidal ideation or plans. The patient can be discharged safely to home from psychiatric point of view.
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