Date of Discharge: 1 November 2024
**Presenting Problem / Reason For Admission:**
The patient presented to the emergency department with acute suicidal ideation and a recent suicide attempt by overdose. The patient reported feeling overwhelmed by stress related to work and relationship difficulties, and expressed a desire to end their life.
**Course of Hospitalization:**
The patient was admitted to the inpatient psychiatric unit for safety and stabilisation. During the hospital stay, the patient received individual therapy, group therapy, and medication management. The patient's suicidal ideation gradually decreased, and they began to engage more actively in treatment. The patient's medication regimen was adjusted to include an antidepressant and an anxiolytic. The patient showed improvement in mood and a reduction in anxiety levels. No complications were noted during the hospital stay.
**Mental Status Examination:**
Appearance: The patient appeared their stated age and was well-groomed. They were dressed in clean, casual clothing.
Behaviour: The patient was cooperative and displayed normal psychomotor activity. They were able to maintain eye contact during the interview.
Speech: The patient's speech was normal in rate, volume, and clarity. The patient was coherent and goal-directed.
Mood: The patient reported feeling sad and anxious, but also expressed some hope for the future.
Affect: The patient's affect was congruent with their stated mood, with a range of emotions expressed appropriately.
Thoughts: The patient's thought process was linear and logical. There was no evidence of psychosis, delusions, or hallucinations.
Perceptions: Patient was not observed to be attending to internal stimuli and denied any auditory or visual hallucinations.
Cognition: The patient was alert and oriented to person, place, and time. Their memory and concentration were intact.
Insight: The patient demonstrated a good understanding of their condition and the need for ongoing treatment.
Judgment: The patient demonstrated good judgment and an understanding of the consequences of their actions.
**Discharge Diagnoses:**
- Primary Psychiatric Diagnosis: Major Depressive Disorder, Recurrent, Severe, with Psychotic Features (F33.3)
- Secondary/Medical Diagnoses: Generalized Anxiety Disorder (F41.1)
**Medications at Discharge:**
- Sertraline 100mg daily, PO, for depression.
- Clonazepam 0.5mg twice daily, PO, for anxiety.
**Disposition:**
- Discharge Setting: Home
- Living Situation: With family
- Support System: The patient has a supportive family and a close friend who will provide emotional support and assist with medication adherence.
**Discharge Risk Assessment:**
The patient's risk of suicide and self-harm was assessed as low at discharge. The patient has a supportive family and a good understanding of their condition. The patient has a crisis plan in place and is committed to attending follow-up appointments.
**Follow-up and Aftercare Plan:**
- Psychiatric Follow-up: Dr. Emily Carter, Psychiatrist, within one week.
- Therapy/Counseling: Individual therapy with Dr. Sarah Jones, LCSW, weekly.
- Medical Follow-up: Primary care physician within two weeks.
- Referrals: Referral to a local support group for individuals with depression.
- Crisis Plan: The patient has been provided with a crisis plan that includes emergency contact information and instructions for what to do in the event of a psychiatric crisis.
**Discharge Instructions:**
The patient was instructed to continue taking their medications as prescribed, attend all scheduled appointments, and contact their psychiatrist or therapist immediately if they experience any worsening of symptoms or suicidal thoughts. The patient was also provided with information about local mental health resources and support groups.
**Discharging Clinician:** Dr. Thomas Kelly, MD, Psychiatrist
Date of Discharge: [Date] (only include Date of Discharge if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
**Presenting Problem / Reason For Admission:**
[Describe the presenting complaint and circumstances that led to admission, using patient’s own words if available.] (only include Presenting Problem if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
[Describe the clinical rationale for psychiatric admission, including acute symptoms, functional decline, risk factors, or psychiatric decompensation.] (only include Reason for Admission if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
**Course of Hospitalization:**
[Provide a Chronological narrative summary of the treatment course, including interventions, clinical response, any complications, significant events, or changes in medication or diagnosis.] (only include Course of Hospitalization if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
**Mental Status Examination: **(ALWAYS write Mental Status Examination in paragraphs of full sentences. NEVER bullet point or list, unless instructed otherwise.)
[Appearance: patient's clothing, hygiene, and any notable physical characteristics] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Behaviour: patient's activity level, interaction with their surroundings, and any unique or notable behaviors] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Speech: rate, volume, clarity, and coherence of the patient's speech] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Mood: patient's self-described emotional state, using their own words if possible] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Affect: range and appropriateness of the patient's emotional response during the examination, noting any discrepancies with the stated mood] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Thoughts: patient's thought process and content, noting any distortions, delusions, or preoccupations] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Perceptions: any reported hallucinations or sensory misinterpretations, specifying type and impact on the patient] [if patient denied AH/VH and there are no perceptual disturbances mentioned by the physician then state -- patient was not observed to be attending to internal stimuli and denied any auditory or visual hallucinations. ] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Cognition: patient's memory, orientation to time/place/person, concentration, and comprehension] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Insight: patient's understanding of their own condition and symptoms, noting any lack of awareness or denial] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[Judgment: patient's decision-making ability and understanding of the consequences of their actions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
(ALWAYS write Mental Status Examination in paragraphs of full sentences. NEVER bullet point or list, unless instructed otherwise.)
**Discharge Diagnoses:**
- Primary Psychiatric Diagnosis: [Diagnosis and ICD-10 code] (only include Primary Psychiatric Diagnosis if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- Secondary/Medical Diagnoses: [List any comorbidities or relevant diagnoses] (only include Secondary/Medical Diagnoses if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
**Medications at Discharge:**
[List all medications prescribed at discharge with doses, frequency, route, and indication.] (only include Medications at Discharge if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
[Include if the medications will be dispensed via daily witness ingestion, DWI] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, else omit section entirely)
**Disposition:**
- Discharge Setting: [Home / Residential Program / Step-down / IOP / PHP / Shelter / Other] (only include Discharge Setting if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- Living Situation: [Living alone / With family / Supervised residence / Homeless / Other] (only include Living Situation if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- Support System: [Describe any family, peer, or social support resources.] (only include Support System if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
**Discharge Risk Assessment:**
[Describe level of risk for suicide, self-harm, or harm to others at discharge, and any protective factors or interventions.] (only include Discharge Risk Assessment if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
**Follow-up and Aftercare Plan:**
- Psychiatric Follow-up: [Provider name and timeframe for follow-up.] (only include Psychiatric Follow-up if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- Therapy/Counseling: [Therapist and next session, if scheduled.] (only include Therapy/Counseling if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- Medical Follow-up: [Primary care or specialty medical appointments.] (only include Medical Follow-up if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- Referrals: [Any additional community resources or programs.] (only include Referrals if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
- Crisis Plan: [Instructions for what to do in the event of psychiatric crisis.] (only include Crisis Plan if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
**Discharge Instructions:**
[List any instructions provided to the patient and/or caregivers, including medication education, activity limitations, warning signs, and emergency contact information.] (only include Discharge Instructions if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
**Discharging Clinician:** [Name and credentials] (only include Discharging Clinician if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript. Ensure the note is detailed and comprehensive)
