Inpatient Behavioral Health Discharge Summary

Patient Name: [Patient full name]

MRN: [Medical record number]

DOB: [Date of birth]

Age: [Age]

Admit Date/Time: [Admit date and time]

Discharge Date/Time: [Discharge date and time]

Attending Psychiatrist: [Attending psychiatrist name and credentials]

Discharging Clinician: [Discharging clinician name and credentials]

Unit/Service: [Inpatient unit or service]

Legal Status at Discharge: [voluntary / involuntary / commitment order] (Specify conditions or court mandates if applicable.)

Disposition: [home / residential / step-down / transfer / other] (Specify receiving location and level of care.)

Reason for Hospitalization

[Narrative of why inpatient psychiatric care was required] (Include referral source and precipitating events; presenting symptoms and acute risk drivers such as suicidal ideation with plan/intent, grave disability, psychosis, mania, violence risk, or detox needs; and relevant context such as recent stressors, medication nonadherence, or substance relapse. Include patient-stated reason when clinically meaningful. Document only observed, reported, or corroborated information; do not infer intent or motive.)

Diagnoses at Discharge

• Psychiatric:
  • [Primary psychiatric diagnosis with ICD-10 code] [definitive / provisional / working]
  • [Secondary psychiatric diagnoses as applicable] (Include only if present.)
• Substance-Related:
  • [Substance use disorder and/or intoxication/withdrawal; specify substance and severity]
• Medical:
  • [Medical conditions affecting psychiatric care]
• Psychosocial/Contextual:
  • [Relevant psychosocial stressors or Z-codes]

(Designate diagnoses as provisional or working when certainty is limited. Omit categories without applicable diagnoses.)

Clinical Formulation

[Biopsychosocial synthesis] (Outline predisposing factors such as illness history, trauma, and family history; precipitating factors such as recent stressors or triggers; perpetuating factors such as substance use, nonadherence, or limited supports; and protective factors such as relationships, engagement, and coping strengths. Include concise diagnostic reasoning for the primary diagnosis and key differentials considered.)

Hospital Course

(Organize by problem from most acute/safety-relevant to least. Include only high-yield information; do not reproduce daily notes.)

[Problem 1: Primary or highest-acuity issue]

[Admission presentation and initial risks/needs]

• Evaluations: [Key assessments, scales, labs, imaging, ECG, toxicology, consultations]
• Interventions: [Medication trials with doses/titrations; therapy/groups; family meetings; withdrawal management; milieu interventions]
• Response: [Clinical changes; behavioral observations; rating scales; objective markers]
• Adverse Events/Complications: [EPS, QTc concerns, metabolic issues, restraint/seclusion, falls, elopement attempts] (Include only if applicable.)
• Consultations: [Services consulted and impact on care] (Include only if applicable.)

[Problem 2]

(Repeat structure for each additional major problem.)

Mental Status at Discharge

• Appearance/Behavior: [General appearance, grooming, cooperation, eye contact]
• Psychomotor: [normal / increased / decreased / abnormal movements]
• Speech: [Rate, volume, prosody, latency]
• Mood/Affect: [Patient-stated mood]; [affect quality, range, reactivity, congruence]
• Thought Process: [logical and goal-directed / circumstantial / tangential / disorganized / other]
• Thought Content: Suicidal ideation: [present / absent]; intent: [yes / no]; plan: [yes / no]. Homicidal ideation: [present / absent]. Delusions: [present / absent]. (If present, describe briefly.)
• Perception: Hallucinations: [present / absent] (If present, specify type.)
• Cognition: [Orientation, attention, memory, executive function as assessed]
• Insight/Judgment: [adequate / limited / impaired]
• Sleep/Appetite: [Brief status] (Include if clinically relevant.)
• Functional Status: [ADLs, ability to follow discharge plan, supervision needs]

(If discharge MSE could not be performed, document reason and best available proxy.)

Risk Assessment at Discharge

• Suicide Risk:
  • Current ideation: [yes / no]; intent: [yes / no]; plan: [yes / no]; preparatory behaviors: [present / absent]
  • Access to lethal means: [Assessment summary and actions taken]
  • History: [Prior attempts or self-harm events]
  • Dynamic risk factors: [Relevant factors such as intoxication, insomnia, psychosis, hopelessness, recent loss]
  • Protective factors: [Supports, reasons for living, treatment engagement, coping strengths]
  • Overall risk level: [low / moderate / high] — [Brief rationale linked to mitigation plan]
• Violence Risk: [Ideation/intent, target-specific threats, access to weapons, history of violence]
• Grave Disability/Self-Neglect: [Ability to meet basic needs, medication adherence capacity, cognitive barriers]
• Substance Relapse/Overdose Risk: [Recent use pattern, cravings, access, overdose prevention provided]

(Required when any suicide risk was present during admission. Risk rationale must be explicit and tied to discharge mitigation plan.)

Safety Plan

Status: [completed and provided to patient / declined / not indicated] (If completed, note storage location. If declined, document alternative mitigation.)

• Warning signs: [Key personal cues]
• Internal coping strategies: [Strategies identified]
• Social supports for distraction: [Names, places, activities]
• People to contact for help: [Names and phone numbers]
• Professional/crisis resources: [Crisis line, mobile crisis, ED with contact details]
• Means safety actions: [Items secured or removed; who will implement]

(Include for any patient with suicide risk during admission.)

Discharge Medications

Reconciliation: [Statement confirming discharge medications reconciled against pre-admission and inpatient orders, or documentation of limitations]

• [Medication name] — [dose] [route] [frequency] — [indication] — [patient-specific instructions as needed]

Medication Changes

• Started: [Medication, indication, expected benefit timeframe]
• Stopped: [Medication, reason]
• Changed: [Medication, nature of change, target symptom]

Monitoring Plan

• Required labs/studies: [Tests, timing, responsible clinician]
• Side effects to monitor: [Key concerns and who is tracking]
• Safety cautions: [Sedation, fall risk, driving restrictions, overdose mitigation]

(If monitoring cannot be arranged, document gap and interim mitigation.)

Pertinent Results and Pending Items

• Key results: [Labs, imaging, ECG, toxicology that influenced diagnosis or medications]
• Pending at discharge: [Test, expected date, responsible clinician for follow-up]

(If nothing pending, state "No pending studies or results.")

Discharge Condition and Disposition

[Summary of psychiatric stability and functional capacity to follow the discharge plan]

Disposition: [home / supervised setting / transfer] (Include level-of-care rationale for step-down placements.)

Legal status: [voluntary / involuntary / commitment order; ongoing legal constraints if any]

Transportation: [Arrangements] (Include only if materially affects safety.)

Aftercare Plan

• Follow-up appointments: [Clinician/service, role, date/time or timeframe, location, contact info, prerequisites]
• Referrals: [PHP/IOP, case management, ACT/CTI, residential, SUD treatment, peer support, medical follow-up]
• Crisis pathway: [Symptoms prompting urgent contact or ED return; how to access crisis services including crisis line, mobile crisis, ED]
• No-show contingency: [Outreach plan for high-risk patients] (Include only for elevated-risk patients.)

(If follow-up not yet scheduled, document reason and interim plan.)

Patient and Family Education

• Medication education: [New medications, dose changes, adverse effects, monitoring instructions reviewed]
• Safety plan and means safety counseling: [Topics reviewed, agreements made]
• Family/support involvement: [Who was involved; consent/ROI status]
• Barriers to adherence: [Identified barriers and mitigation strategies]

Care Coordination

• Documents sent to: [Recipients and transmission method]
• Verbal handoff: [Yes / No] (If yes, to whom and key content.)

(If documents could not be transmitted, note barrier and plan.)