Discharge Summary Narrative

Psychiatry
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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"]
Identifying Information:
Patient name is a age-year-old, ethnicity, who in residing location. Patient's diagnosis on admission: admission diagnoses. discharge diagnoses.

Reason for Admission:
presentation info reason

Course of Treatment:
. additional info

Progress/Response to treatment:
On admission home medications. The patient was admitted to the . additional info medication trials and result Description of improvement throughout hospitalization additional disposition info

Mental Status Exam:
Patient presents as . additional information about memory additional information about attention span/concentration Their language skills are . additional information about language Their fund of knowledge appears . additional information about fund of knowledge additional information about abstraction They appear to be additional information about appearance Their behavior presents as with additional information about behavior . additional information about muscle strength. Speech is . Vocabulary is . additional information about speech Thought processing and content present as . additional information about thought process additional information about thought content Their judgment concerning everyday activities is additional information about judgment Their insight concerning their psychiatric condition is additional information about insight

Risk Assessments:
The patient is at a acute and chronic risk of suicide based on and treated psychiatric symptoms at this time. The patient has . They present as . additional information about suicide risk factors
The patient is at a acute and chronic risk of violence based on and treated psychiatric symptoms at this time. The patient had . Prior to admission the patient had . additional information about violence risk factors

Medical Issues Addressed During Hospitalization:
abnormal laboratory information if applicable additional information about medical issues and interventions

Prognosis:
Prognosis is considering the patient remains adherent to medication and therapy to address target of treatment . barriers strengths
Result - Copy and paste this output:

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