A Discharge Note a communication between the treating clinician and the next person/agency involve in the care of a client. It is created when a patient’s case is closed and referred to another provider either by discharge from an inpatient or outpatient program or if a patient is deceased. The Discharge Note provides closure between a provider and a client. The closures can occur in two ways, written and/or oral. In this assignment, students will produce either a written or an oral discharge note to assist them in practice when a Discharge Note is appropriate. A Discharge Note is a part of the Chart, a legal document and must be treated as such.
Following the information from a patient interview, chart review and/or your preceptor; upload your note or your oral presentation to Blackboard. If you choose a dictated summary it must be verbatim of what would have been written.
NOTE: If you did not have the opportunity of discharging a client in your practicum experience, discuss with your preceptor and formulate the plan to discharge one to your preceptor.
REASON FOR DISCHARGE NOTE:
DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
DISCHARGE DIAGNOSES: Medical and Psychiatric
REASON FOR ADMISSION:
HISTORY: Make this brief but significant
PROCEDURES AND TREATMENT:
1. Individual and group psychotherapy. – BE SPECIFIC
2. Psychopharmacologic management. – BE SPECIFIC
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: Brief discussion of how the hospitalization went. All intervention implemented and client’s response to therapy.
DISCHARGE ASSESSMENT: client current condition at the time of transfer, including mental status exam.
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ASSETS and LIABILITIES: this include strengths, weaknesses, support system, and Maslow
SHORT TERM GOALS and LONG-TERM GOALS: determined by staff with patient input, address each goal and progress toward that goal
DISCHARGE PLAN: The risk for harm, medications, labs, teaching, labs, referrals, and follow-ups. All transfer information as arranged by case manager and social work