Inpatient Psychiatry Discharge Summary (Child/Adolescent)

Patient: [Full name]

MRN: [Medical record number]

Date of Birth: [YYYY-MM-DD]

Age: [Age in years]

Legal Guardian(s) & Custody Status: [Guardian name(s) and legal authority; custody arrangement: biological parent / foster placement / kinship care / shared custody / state custody / other]

Admission Date: [YYYY-MM-DD]

Discharge Date: [YYYY-MM-DD]

Length of Stay: [Number of days]

Attending Psychiatrist: [Name, credentials]

Other Treating Clinicians: [Roles and names] (Only include if applicable)

Discharge Disposition: [home / foster home / kinship placement / residential treatment center / PHP / IOP / shelter / other]

Primary Outpatient Recipients: [Psychiatrist: name/clinic] | [Therapist: name/clinic] | [PCP: name/clinic] | [School contact: name/role] (Include school contact only with documented consent)

Reason for Hospitalization

[1–3 sentence synopsis of precipitating event and immediate safety concerns leading to admission] (Include source of history. A brief direct quote may be included if it clarifies intent. If the precipitant is disputed, document competing accounts.)

Diagnoses

• Primary Psychiatric Diagnosis: [Primary DSM diagnosis]
• Secondary Psychiatric Diagnoses: [Neurodevelopmental, trauma-related, substance-related diagnoses] (Only include if applicable)
• Relevant Medical Diagnoses: [Medical conditions affecting psychiatric care or medication safety] (Only include if applicable)

[Diagnostic clarification] (If diagnoses changed during admission, briefly note the admission working diagnosis and what led to revision. Include brief differential only when it materially affects follow-up.)

Psychosocial/Contextual Factors: [Family conflict, housing/placement stability, school stressors, legal or child welfare involvement, other salient social determinants] (Only include factors relevant to formulation and discharge planning)

Pertinent History

• [Prior psychiatric diagnoses and hospitalizations]
• [Suicide attempt and self-harm history including methods, dates, medical lethality if known]
• [Prior medication trials, responses, and notable intolerances]
• [Prior and current therapy; outpatient provider engagement]
• [Relevant developmental history and neurodevelopmental diagnoses]
• [Family psychiatric history] (Only include if pertinent to formulation)
• [Substance use including nicotine/vaping, cannabis, alcohol, other substances]
• [Baseline functioning: school performance, IEP/504 status, peer relationships, sleep]

Hospital Course

(Organize by major problems or clinical themes rather than day-by-day chronology.)

[Problem/Theme: e.g., suicidal ideation, mood instability, aggression, psychosis]

• Interventions: [Observation level, medication changes, therapy modalities, family work, safety planning, milieu/skills groups, school programming]
• Response: [Clinical response, engagement, notable side effects or adverse reactions]
• Status at Discharge: [Current symptom status and functional level]

(Repeat problem/theme structure for each major clinical issue addressed.)

• Significant Events: [Restraint/seclusion episodes, assaults, elopement attempts, medical complications, adverse medication reactions] (Only include if occurred and relevant to aftercare)
• Consultations: [Pediatrics, neurology, psychology/neuropsych testing with key findings]
• Collateral Contacts: [Caregivers, school, outpatient providers contacted; key information obtained; consent documented]
• Clinically Actionable Labs/Studies: [Metabolic panel, EKG QTc, lithium/valproate levels, pregnancy test, toxicology results]

Diagnostic Formulation

Predisposing factors: [Developmental, trauma history, neurobiology, family history]

Precipitating factors: [Recent stressors, losses, medication changes, substance use]

Perpetuating factors: [Ongoing stressors, sleep disruption, limited supports, access to means]

Protective factors: [Engaged caregivers, future orientation, treatment engagement, positive connections, reasons for living]

Treatment implications: [How the formulation informs safety plan intensity, monitoring, and aftercare recommendations]

Medications

Allergies and Adverse Reactions: [Allergen(s) and reaction type; state "reaction unknown" if unknown; state "NKDA" if no known allergies]

Discharge Medication List: (Provide complete active list; do not reference elsewhere in chart.)

• [Medication name] — [dose] [route] [frequency] — [indication]

(Repeat for each medication.)

Medication Changes During Admission:

• [New start / discontinuation / dose change of medication name]: [Target symptom; clinical reasoning; observed response; notable side effects; monitoring plan]

(Repeat for each medication change.)

Required Monitoring: [Labs and timing, EKG follow-up if applicable, who is responsible for ordering/reviewing] (Only include if ongoing monitoring required)

High-Risk Regimen Justification: [Clinical justification and time-limited plan for polypharmacy or off-label use] (Only include if applicable)

Mental Status at Discharge

• Appearance/Behavior: [Appearance and behavior observations]
• Speech: [Speech characteristics]
• Mood/Affect: [Mood] / [Affect]
• Thought Process: [Thought process description]
• Thought Content: [Suicidal/homicidal ideation, delusions, obsessions—current status]
• Perceptions: [Hallucinations or perceptual disturbances]
• Insight/Judgment: [Insight and judgment assessment]
• Cognition: [Orientation, attention, memory as assessed]
• Impulse Control: [Impulse control assessment]

Clinical Trajectory: [Brief narrative of improvement from admission to discharge; residual symptoms; functional status including sleep, appetite, ADLs, school readiness, family interactions]

Risk Assessment at Discharge

(Explicitly document current findings and assign risk level for each domain. If any domain was not assessed on the day of discharge, state why.)

• Suicide/Self-Harm: [Current ideation, plan, intent; access to means; recent attempts or NSSI during admission; identified triggers; protective factors] — Risk Level: [low / moderate / high] — [Brief justification]
• Violence/Aggression: [Current risk toward others; relevant history; access to weapons] — Risk Level: [low / moderate / high] — [Brief justification]
• Runaway/Elopement: [History and current intent] — Risk Level: [low / moderate / high] — [Brief justification] (Only include if clinically relevant)
• Required Supervision at Discharge: [Level of supervision required and who will provide it]

Safety Plan

[Document that a collaborative safety plan was created or reviewed near discharge; participants; location of full plan]

• Warning Signs: [Personal warning signs identified]
• Internal Coping Strategies: [Self-management techniques]
• People/Places for Distraction: [Social supports and safe environments]
• People to Contact for Help: [Names, relationships, contact information]
• Professional/Crisis Resources: [Outpatient team contacts; 988 Suicide & Crisis Lifeline; local crisis services]
• Emergency Steps/ED Return Criteria: [When to go to the emergency department]

(If a safety plan was not completed, document why and describe the interim plan.)

Means Safety Counseling

• Lethal Means Assessed: [Firearms, medications, sharps, ligatures, toxins, other items relevant to patient's history or stated plan]
• Counseling Provided: [Safe storage, removal, locking, limiting medication quantities, separating ammunition, supervision of access]
• Agreed-Upon Plan: [Specific measures and who will implement each]
• Implementation Status: [confirmed prior to discharge / not confirmed with reason] (If caregivers declined, document refusal, risk discussion, and alternative mitigations.)

Discharge Plan and Aftercare

Disposition & Handoff: [Physical destination; responsible adult at handoff; custody/placement details]

School Re-entry: [Return-to-school date; need for IEP or 504 review; recommended accommodations; school counselor coordination; consent status] (Only include if applicable)

Follow-up Appointments:

• [Provider name and role] — [Clinic / Telehealth] — [Phone] — [Date/Time] — [Purpose and urgency]

(Repeat for each scheduled appointment. Indicate urgency based on risk level, e.g., psychiatry within 72 hours for high risk, within 7 days for moderate.)

Medication Management: [Who will prescribe refills; supply provided at discharge; when labs are due and who orders/reviews]

Crisis Follow-up: [Who will contact the patient/family after discharge and when; what to do if appointments are missed]

Barriers & Mitigations: [Transportation, insurance, language, technology, caregiver availability; mitigations arranged] (Only include if barriers identified)

(If any appointment is not yet scheduled, document steps taken, contingency resources, interim medication supply, and who is responsible for finalizing.)

Pending Items

• [Pending test/result or task] — [Expected completion] — [Responsible party] — [Plan for review and communication to family/outpatient team]

(Repeat for each pending item. Omit section if no pending items.)

Patient and Family Education

• [Diagnoses and treatment course explained in developmentally appropriate language]
• [Warning signs of relapse and when to seek help reviewed]
• [Medication side effects and black box warnings discussed; written materials provided]
• [Skills reviewed: coping strategies, sleep hygiene, emotion regulation]
• [Written instructions provided in preferred language and accessible format]
• [Treatment refusals and counseling provided] (Only include if applicable)

Communication and Records Transmission

• Recipients: [Names and organizations receiving discharge summary/continuing care plan; method; date sent]
• Release of Information: [ROI status and any confidentiality constraints]
• Clinician-to-Clinician Handoff: [Date; clinician contacted; key points discussed] (Only include if handoff call occurred)