Nurs 687 LWeek 4 Collaborative Learning: Psychiatric Patient Discharge Summary
Note
Submit a psychiatric discharge summary note in the discussion board. You
must use an actual patient from your clinical, but remove all identifying
information (names, places, etc.) so that it is HIPAA compliant.
A Discharge Summary is created when a patient is discharged from an
inpatient setting or outpatient program and the patient’s case is closed. The
note is therefore a communication between the treating clinician and the
next provider or agency involved. Discharge summaries are also written
when the patient is deceased.
You may use the format below for your note, or the format you use at your
clinical site.
Respond to two peers with the following: Read another student’s progress
note and assume that you are a PMHNP who will see this patient in an
outpatient practice for follow up. Is there anything that wasn’t clear in the
note that you would like to ask your NP colleague? Also, assume the patient
isn’t tolerating the medication when you see them in follow up. Identify an
alternative medication that would be appropriate and why you would
choose it.
Due: Initial post due by Wednesday and responses are due by Sunday,
11:59 p.m. (Pacific time)
Example:
REASON FOR TRANSFER SUMMARY: This is a transfer summary on XX
as patient will be leaving the x today and will be transitioned to X
DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
DISCHARGE DIAGNOSES: Medical and Psychiatric
REASON FOR ADMISSION: The patient was admitted with a chief complaint
of ____________. The patient was brought to the hospital after his guidance
counselor found a note the patient wrote, which detailed who he was giving away
his possessions to if he dies. The patient told the counselor that he hears voices
telling him to hurt himself and others. The patient reports over the last month
these symptoms have exacerbated. The patient had a fight in school recently,
which the patient blames on the voices. Three weeks ago, he got pushed into a
corner at school and threatened to shoot himself and others with a gun. The
patient was suspended for that remark.
PSYCHIATRIC HISTORY: Keep it 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 hospitalization – how things
went. The patient responded well to individual and group psychotherapy, milieu
therapy and medication management. As stated, family therapy was conducted. –
HOW DID THESE ALL GO?; Discuss all
action taken on behalf of the patient, results (medication trials; responses/ diagnost
ics, treatments)
DISCHARGE ASSESSMENT: 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.
ASSETS and LIABILITIES: this is strengths/weaknesses/support
system/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 patient may be discharged as he no longer poses a risk
of harm towards himself or others. The patient will continue on the following
medications; Ritalin LA 60 mg q.a.m., Depakote 500 mg q.a.m. and 750
mg q.h.s., Abilify 20 mg q.h.s. Depakote level on date of discharge was
110. Liver enzymes drawn were within normal limits. The patient will follow up
with Dr. Doe for medication management and Dr. Smith for psychotherapy. All
other discharge orders per the psychiatrist, as arranged by social
work. Any other treatment recommendations
Thank you for receiving this summary.
Signature: current credentials, PMHNP student
Week 6 Collaborative Learning: Psychiatric Therapy Note
N
The purpose of these assignments are to allow the student to learn how to
do various types of notes that the PMHNP might be called upon to write in
the course of their career. Therapy notes are meant to be brief and often
follow the Data, Assessment, Plan (DAP) format.
D- Data= This section should include what behaviors were observed during
the therapy and anything that might be pertinent to how you want to
proceed with the therapy treatments.
A- Assessment= What is your assessment of the behaviors and what do
they mean in relation to the therapy you are using. What do you think the
client’s actions mean? Are the clients progressing toward the goals?
P- Plan= Record the treatment plan for your patient.
Important: Therapy notes are not a part of the regular patient chart. They
should be released to patients if it is determined that the contents could be
psychologically harmful.
Respond to two peers with the following: Read another student’s therapy
note and pretend that you are the NP who will see this patient next. Is there
anything that wasn’t clear in the note that you would like to ask your NP
colleague? Realize that none of us ever have enough time with our patients,
but what is one thing you would have liked to ask this patient? Also, assume
the patient isn’t tolerating the medication when you see them in follow up.
Identify an alternative medication that would be appropriate and why you
would choose it.
Example:
D- Met with M for 45 minutes via virtual session. Today she is reporting
that she is in training at Amazon and it is going well. She reports that she is
anxious about the 2 hour bus ride and that her work hours are overnight, so
she is coming/ going in the dark. She is also worried about having too many
badges to scan at work and afraid she will ‘mess up’. She states she was
anxious about finding her way in the large building but there are markings
on the floor to guide her and after a few days she is feeling more at ease.
She is not wanting to return to community college now that she has found
this employment that is not a seasonal job.
A- Monica has made improvement in her anxiety symptoms and seems
quite proud of her progress and accomplishments with the new job. We
discussed her past patterns of putting pressure on herself and over thinking.
She has already overcome one obstacle by navigating the large building and
can use the same skills for the other stressors that cause her anxiety at this
new job.
P- HW: Breathing and mindfulness techniques when feeling anxious.
Speaking up politely if feeling overwhelmed at new job. Talk with
grandmother about not going back to college. Next session in 1 week.