Complete and submit an outstanding discharge note from an actual patient you cared for during practicum experience.  If you did not have the opportunity of discharge a client during your practicum experience, discuss with your preceptor and formulate the plan to discharge a client to your preceptor.

Discharge Note

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