Discharge Summary Narrative

Identifying Information:
[text memo="Patient name" size="20"] is a [text memo="age" size="2"]-year-old, [text memo="ethnicity" size="20"], [checkbox value="single|married|partnered"] [checkbox value="female|male|transgender female|transgender male|gender non-binary individual"] who [checkbox value="lives alone|is homeless|lives with significant other|lives with parents|lives with a roommate"] in [text memo="residing location" size="20"]. Patient's diagnosis on admission: [textarea memo="admission diagnoses" rows="5"].  [checkbox value="The patient’s diagnoses were not changed during the course of admission.|Diagnosis changed to:"][textarea memo="discharge diagnoses" rows="5"]. 

Reason for Admission:
[checkbox value="The patient arrived at the emergency department "][checkbox value="The patient was seen at an outpatient appointment "][checkbox value="The patient was seen for an emergency outpatient appointment "][textarea memo="presentation info" rows="1"][checkbox value="alone |with family |with significant other |by police "][textarea memo="reason" rows="5"]

Course of Treatment:
[checkbox value="The patient was exposed to individual, group, and milieu based therapies"][checkbox value=" in addition to medication management"].  [textarea memo="additional info" rows="3"]

Progress/Response to treatment:
On admission [checkbox value="the patient was prescribed no home medications|the patient maintained the following medications: "][textarea memo="home medications" rows="5"]. The patient was admitted [checkbox value="voluntarily |involuntarily "]to the [checkbox value="psychiatric observation unit|inpatient unit"].  [textarea memo="additional info" rows="8"] [checkbox value="Medications trialed this admission include: "][textarea memo="medication trials and result" rows="5"] [textarea memo="Description of improvement throughout hospitalization" rows="5"] [checkbox value="The patient denied any suicidal or homicidal ideation, and reported that they felt ready to return home. "][checkbox value="There were no further concerns expressed by social contacts or by members of the treatment team.  "][textarea memo="additional disposition info" rows="5"]

Mental Status Exam: 
Patient presents as[checkbox value=" alert and oriented to "][checkbox value="person|place|time"][checkbox value=", disoriented to "][checkbox value="person|place|time"]. [checkbox value="Recent and remote memory are intact. "][textarea memo="additional information about memory" rows="3"] [checkbox value="Attention span and concentration are adequate. "][textarea memo="additional information about attention span/concentration" rows="3"] Their language skills are [checkbox value="adequate|limited|consistent with education|inconsistent with education"]. [textarea memo="additional information about language" rows="3"] Their fund of knowledge appears [checkbox value="appropriate for stated age and education level|inappropriate for stated age and education level"]. [textarea memo="additional information about fund of knowledge" rows="3"] [checkbox value="They are capable of abstraction. |They display difficulty with abstraction. "][textarea memo="additional information about abstraction" rows="3"] They appear to be [checkbox value="their stated age|younger than their stated age|older than their stated age|well groomed|unkempt|appropriately dressed|inappropriately dressed|in their own clothes|in hospital clothes|normal posture.  |slumped posture.|rigid posture."][textarea memo="additional information about appearance" rows="3"] Their behavior presents as [checkbox value="calm|restless|agitated|irritable|impulsive|inattentive|interactive|withdrawn"] with [checkbox value="good eye-contact. |avoidant eye-contact. "][textarea memo="additional information about behavior" rows="3"] [checkbox value="They are incapable of ambulating|Their gait presents as "][checkbox value="normal|abnormal|unsteady|shuffling|spastic"].  [checkbox value="Muscle strength and tone are "][checkbox value="equal for all limbs with free range of motion"][textarea memo="additional information about muscle strength" rows="3"]. Speech is [checkbox value="a regular rate and rhythm|spontaneous|appears prepared|hyperverbal|rapid|slow|rambling|slurred|monotone|pressured|laconic|normal volume|quiet|loud"]. Vocabulary is [checkbox value="adequate|large|limited"]. [textarea memo="additional information about speech" rows="3"] Thought processing and content present as [checkbox value="adequate|delayed|logical|illogical|reality based|disorganized|circumstantial|tangential|flight of ideas|loose association|perseveration|thought blocking|ideas of reference|grandiose|paranoid|persecutory|religious|somatic|self accusatory"]. [textarea memo="additional information about thought process" rows="3"] [checkbox value="No evidence of hallucinations or delusions. "][checkbox value="No evidence of preoccupation with violence. "][checkbox value="They deny suicidal and homicidal ideation. "][textarea memo="additional information about thought content" rows="3"] Their judgment concerning everyday activities is [checkbox value="good. |fair. |poor. |impaired. "][textarea memo="additional information about judgment" rows="3"] Their insight concerning their psychiatric condition is [checkbox value="good. |fair. |poor. |impaired. "][textarea memo="additional information about insight" rows="3"]

Risk Assessments: 
The patient is at a [select value="low|moderate|high"] acute and [select value="low|moderate|high"] chronic risk of suicide based on [checkbox value="lack of current suicidal ideation|current suicidal ideation|intent"] and [select value="well|moderately|poorly"] treated psychiatric symptoms at this time.  The patient has [checkbox value="no history of suicide attempts|a history of suicide attempts|a recent history of suicidal ideation|difficulty with supportive relationships|a minimal support system outside the hospital"]. They present as [checkbox value="future oriented|with plans for self-improvement|having a strong sense of personal responsibility|ambivalent about personal outcomes|pessimistic about personal outcomes"]. [textarea memo="additional information about suicide risk factors" rows="3"] 
The patient is at a [select value="low|moderate|high"] acute and [select value="low|moderate|high"] chronic risk of violence based on [checkbox value="lack of current violent ideation|current violent ideation|intent"] and [select value="well|moderately|poorly"] treated psychiatric symptoms at this time. The patient had [checkbox value="a lack of violent behaviors on the unit|agitated behaviors on the unit|agitated and violent behaviors on the unit|displayed adequate mood regulation|displayed difficulty with mood regulation"]. Prior to admission the patient had [checkbox value="no history of agitation and violence|a recent history of agitation and violence|difficulty with mood regulation|but has improved significantly with treatment|has made moderate improvement with treatment|has made minimal improvement with treatment|has made no improvement with treatment"]. [textarea memo="additional information about violence risk factors" rows="3"]

Medical Issues Addressed During Hospitalization: 
[checkbox value="There were no acute medical issues addressed during hospitalization. "][checkbox value="There were no abnormal laboratory values noted. |Notable abnormal laboratory values this admission include: "][textarea memo="abnormal laboratory information if applicable" rows="3"][checkbox value=" which resolved without intervention. "][textarea memo="additional information about medical issues and interventions" rows="3"]

Prognosis:
Prognosis is [select value="good|fair|poor"] considering the patient remains adherent to medication and therapy to address [textarea memo="target of treatment" rows="1"][checkbox value=" and whether they are able to engage constructively with social supports"]. [checkbox value="Barriers to success outside of hospitalization include: "][textarea memo="barriers" rows="3"] [checkbox value="Patient strength for success outside of hospitalization include: "][checkbox value="were willing and able to seek treatment|have positive social supports|are well connected with outpatient supports|have a history of actively engaging in outpatient treatment"][textarea memo="strengths" rows="3"]