Bipolar Disorder Psychiatric Discharge Summary Example Report
DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
IDENTIFICATION: The patient is a (XX)-year-old male who was admitted to the psychiatric unit as a transfer.
REASON FOR HOSPITALIZATION: The patient was admitted on an involuntary status due to suicidal ideation. He stated that he had a plan to kill himself the next day. He had reported feeling increasingly depressed. He said he was not able to obtain his disability, which he had attempted to pursue. He was tearful and very negative about everything. He was also verbally abusive at times and complaining of difficulty sleeping. He stated he had been drinking 1-2 pints a day of alcohol since age 12. He had a history of alcohol dependence and a history of heroin use. He quit many years ago, he stated. He had 3 DUIs in the past and had a suspended license 8 times in the past. He also stated that he had jail time in the past and had episodes of blackouts. Currently, he lives with his wife.
COURSE OF TREATMENT: The patient was admitted on an involuntary status and was able to sign a voluntary. Dr. John Doe was requested to follow the patient for any medical concerns during his stay, including a history of coronary artery bypass, hypertension, hypercholesterolemia, and hepatitis.
MEDICATIONS: Lexapro 10 mg daily, Lamictal 25 mg daily, and Ativan 1 mg p.o. q. 4 hours daily.
On admission, the social worker met with the patient to discuss his status and also discharge plans. He stated that he lives with his wife and planned to live there. He is unemployed, and he had an appointment with Social Security on the phone to pursue his disability. He stated he did not want treatment for alcohol abuse at this time. He has a history of noncompliance with followup treatment.
On the unit, he appeared to be angry and verbally abusive towards staff. He stated that he did not want to be here at admission. He was also upset because he was unable to smoke in the hospital. He answered questions abruptly by giving “yea” response for yes and “nah” for no. He also maintained poor eye contact initially.
His social worker talked to the wife regarding setting up a family meeting. She was agreeable to do so. When the social worker spoke to the patient on MM/DD/YYYY, he minimized all the events that led to his admission. He stated “I just thought about ending my life, I never said I would do it.” He stated that his mother died in (XXXX). He had legal problems and was currently on house arrest. He also had recent cardiac problems. He stated that all those created stress for him.
Dr. Jane Doe met with the patient and discussed his medications, including purpose, side effects, and risks. They also discussed the importance of followup care and maintaining outpatient appointments. He began to be less labile in the unit and appeared to be responding to the structure of the unit. On MM/DD/YYYY, a family session was planned for the patient. If it went well, the patient was to be discharged. The family session was held on MM/DD/YYYY with the patient’s wife and the patient. They both felt that he was ready for discharge. He denied suicidal or homicidal ideations. The wife is very supportive of the family. The patient and the wife were given several referrals during the family session, and he was also referred to a facility for his history of alcohol and drug abuse. He felt like he was ready for discharge. The patient had requested a letter from Dr. Jane Doe stating that he was unable to work and that was given to him for the social security disability. It was decided that the patient was ready for discharge after the family meeting.
MENTAL STATUS EXAM ON DISCHARGE: The patient was alert and oriented x4. He denied suicidal, homicidal thoughts or auditory or visual hallucinations. He remained hypoactive and withdrawn to himself. His thoughts were coherent, logical, and goal directed. He had clear and spontaneous speech and good memory.
DISCHARGE MEDICATIONS: Thiamine HCl 100 mg, magnesium oxide 400 mg daily, ASA 325 mg daily, docusate sodium 100 mg b.i.d., multivitamin 1 daily, Lexapro 10 mg daily, Lamictal 25 mg daily, Coreg 6.25 mg b.i.d., Carafate 1 gram q.i.d., Zofran 4 mg q. 6 hours, Protonix 40 mg b.i.d., Lipitor 10 mg nightly, Zestril 20 mg b.i.d., and morphine sulfate 15 mg b.i.d.
DISCHARGE DIAGNOSES:
Axis I:
1. Bipolar disorder, not otherwise specified.
2. Alcohol dependence.
Axis II: Deferred.
Axis III: Coronary artery disease, hypertension, and hepatitis C.
Axis IV: Current health problems.
Axis V: Global Assessment of Functioning of 55.
DISCHARGE DISPOSITION: The patient was discharged home with his wife. He was given a referral to different psychiatrists for his bipolar disorder and also a referral to a facility for his drug abuse history. Dr. John Doe gave medical clearance with recommendation that he follow up with a primary care physician within 1 week after discharge. He was also referred to AA meetings. Home health was ordered for medication, education compliance and home safety. At the time of discharge, all discharge instructions were reviewed with the patient and his wife. They were also educated again regarding the importance of medication compliance and also compliance with making appointments. He verbalized understanding of all discharge plans at the time of discharge. At the time of discharge, he left with his wife in no acute distress, and no complaints were voiced.
