
Date
of Last Review 6/6/07
SME: Medical Director
The responsible resident physician documents the Discharge Summary at the time
of the patient's discharge.
Documentation is due on the day of a planned discharge, and within 24 hours following an unplanned discharge.
The following is a summary of the elements of the Discharge Summary document that the responsible resident physician must write at the time of discharge:
![]() | Patient Name, Medical Record Number, Date of Birth, Age, Admission Date, Date of Discharge |
![]() | History of Current Clinical Episode |
![]() | Evaluations |
![]() | Clinical Course |
![]() | Condition on Discharge |
![]() | Discharge Diagnosis |
![]() | Axis I primary, and secondary (if present) |
![]() | Axis II |
![]() | Axis III |
![]() | Axis IV |
![]() | Axis V |
![]() | Discharge and Aftercare Plan |
![]() | Discharge Summary Documented By |
![]() | Discharge Physician Signature |
The history of current clinical episodes summarizes the current episode as it appears on the Admission History and Physical and Psychiatric Evaluation form
The evaluations element includes the following:
![]() | Lists the evaluation and assessment procedures during hospitalization, specifying the impact on treatment and follow-up on abnormal results |
![]() | Includes, as appropriate, any tests |
Clinical course includes the following as a result of the patient's stay:
![]() | Summarizes the patient's progress in behavioral terms, addressing progress on treatment plan goals and objectives as observed chronologically in the progress notes. |
![]() | Briefly states how the treatment provided prepared the patient for discharge and the aftercare program |
![]() | Writes any use of medications and results |
Condition on discharge includes describing the patient's mental and physical condition on the day of discharge in behavioral terms compared to that of admission.
Terms not to use: Stable, improved, satisfactory, or other vague terms as the description of the condition on discharge
When a diagnosis has been made, document diagnostic codes and diagnosis for each axis as follows:
![]() | Uses DSM-IV TR Plus code numbers and terms following DSM-IV TR Plus instructions |
![]() | On Axis III, includes any significant conditions identified |
Terms not to use: Deferred, rule out, history of, versus
This table describes the discharge and aftercare plan:
Plan Part |
Description |
Medication and appointments |
Dictates medication prescribed to the patient at the time of discharge |
Level of activity |
Notes the level of activity expected of the patient upon discharge including requirements and restrictions |
Diet on discharge |
Notes any dietary needs of the patient upon discharge, including requirements and restrictions |
The person who dictates the requirements writes his/her full name followed by the degree initials.
The attending physician signs his/her full name of the discharge attending physician followed by degree initials.
The Joint Commission : Provision of Care

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