Date
of Last Review 7/22/09
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 |
| Reason for Hospitalization |
| Evaluations |
| Clinical Findings |
| Condition at Discharge |
| Discharge Diagnosis |
 | Axis I primary, and secondary (if present) |
| Axis II |
| Axis III |
| Axis IV |
| Axis V , Admission and Discharge GAF |
| Discharge and Aftercare Plan |
| Discharge Summary Documented By |
| Discharge Physician Signature |
The reason for hospitalization summarizes the current episode as it appears on the Initial 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 findings 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. |
| Clinical findings includes the following as a result of the patient's stay: |
| Documents 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.
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 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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