Psychiatric Discharge Summary Medical Transcription Sample Report




1. Bipolar disorder, depressed, with psychotic features, symptoms in remission.
2. Attention deficit hyperactivity disorder, symptoms in remission.
AXIS II: Deferred.
AXIS IV: Moderate.
AXIS V: Global assessment of functioning 65 on discharge.

REASON FOR ADMISSION: The patient was admitted with a chief complaint of suicidal ideation. The patient was brought to the hospital after his guidance counselor found a note the patient wrote, which detailed who he was giving away his possessions to if he dies. The patient told the counselor that he hears voices telling him to hurt himself and others. The patient reports over the last month these symptoms have exacerbated. The patient had a fight in school recently, which the patient blames on the voices. Three weeks ago, he got pushed into a corner at school and threatened to shoot himself and others with a gun. The patient was suspended for that remark.


1. Individual and group psychotherapy.
2. Psychopharmacologic management.
3. Family therapy conducted by social work department with the patient and the patient’s family for the purpose of education and discharge planning.

HOSPITAL COURSE: The patient responded well to individual and group psychotherapy, milieu therapy and medication management. As stated, family therapy was conducted.

DISCHARGE ASSESSMENT: At the time of discharge, the patient is alert and fully oriented. Mood euthymic. Affect broad range. He denies any suicidal or homicidal ideation. IQ is at baseline. Memory intact. Insight and judgment good.

PLAN: The patient may be discharged as he no longer poses a risk of harm towards himself or others. The patient will continue on the following medications; Ritalin LA 60 mg q.a.m., Depakote 500 mg q.a.m. and 750 mg q.h.s., Abilify 20 mg q.h.s. Depakote level on date of discharge was 110. Liver enzymes drawn were within normal limits. The patient will follow up with Dr. Doe for medication management and Dr. Smith for psychotherapy. All other discharge orders per the psychiatrist, as arranged by social work.

Psychiatric Discharge Summary Sample Report #2



IDENTIFYING DATA: The patient is a (XX)-year-old married Hispanic female.

PERTINENT PSYCHIATRIC HISTORY: Please see complete history and physical.

HOSPITAL COURSE AND TREATMENT: The patient presented as a result of worsening depressive symptoms shortly after she was discharged from this facility. She reports that she was switched from Paxil 50 mg to 30 mg and the outpatient psychiatrist suggested this switch of medication. During the hospitalization, however, she reported that she did very well on Anafranil in the past due to obsessive-compulsive symptoms in addition to assisting with the depressive symptoms.

As a result, the patient’s Paxil was tapered off and she was started with Anafranil 50 mg p.o. q.h.s., which was later increased to 100 mg h.s. She also had Restoril 30 mg p.o. q.h.s. for insomnia and she remained on Zocor 20 mg q.h.s. and Cozaar 100 mg p.o. daily. For the rest of her hospitalization, she was stable. Initially, the patient requested ongoing inpatient residential treatment. However, her insurance company would not cover that and the patient expressed clear understanding. She denied all ideations, and at the time of her discharge, she was stable.

DISPOSITION: The patient was discharged home with a followup appointment.

DISCHARGE MEDICATIONS: Clonazepam 0.5 mg p.o. t.i.d. p.r.n., Cozaar 100 mg daily, Pravachol 40 mg p.o. q.h.s., Restoril 30 mg p.o. q.h.s., and Anafranil 100 mg p.o. q.h.s.

Axis I:
1. Major depressive disorder, recurrent, moderate without psychotic features.
2. Obsessive-compulsive disorder.
Axis II: Deferred.
Axis III:
1. Hypercholesterolemia.
2. Type 2 diabetes.
3. Hypertension.
4. Polycystic ovary disease.
Axis IV: Severity of psychosocial stressors, moderate.
Axis V: Global Assessment of Functioning on admission 30, on discharge 55.

Psychiatric Discharge Summary Sample Report #3




Axis I: Major depressive episode, recurrent, rule out psychotic features, rule out posttraumatic stress disorder, rule out complicated bereavement.
Axis II: Deferred.
Axis III: None.
Axis IV: Mild.
Axis V: Global Assessment of Functioning 70.

DISCHARGE MEDICATIONS: Remeron 15 mg p.o. q.h.s., Lexapro 20 mg p.o. every day, and Risperdal 0.5 mg p.o. b.i.d.

The patient received psychiatric assessment, medication management, and individual therapy.

HOSPITAL COURSE: Significant for the patient slowly adjusting to routine. The patient remained constricted and depressed but gradually improved with time. The patient tolerated medications without difficulty. The patient was able to meet with chaplain to further discuss bereavement issues.

Upon discharge, the patient is to return with parents. She remained calm and cooperative. Her affect had improved and her mood was less depressed. There were no overt delusions or hallucinations. The patient denies any suicidal ideations or homicidal ideations.

At the time of discharge, the patient was not an imminent danger to herself or others.

Psychiatric Discharge Summary Sample Report #4



1. Chronic schizophrenia, undifferentiated type.
2. Post-traumatic stress disorder, impulse control disorder, not otherwise specified.
AXIS II: Mild mental retardation.
AXIS III: History of seizure disorder and diabetes mellitus.
AXIS IV: Moderate.
AXIS V: Global assessment of functioning is 40.

DISCHARGE MEDICATIONS: Wellbutrin SR 100 mg every day, glipizide 5 mg by mouth every day, Geodon 200 mg by mouth at bedtime, Trileptal 300 mg by mouth 3 times a day, and trazodone 150 mg by mouth at bedtime.

The patient received psychiatric assessment, medication management, and individual and group therapy.

Hospital course was remarkable for the patient being resumed on her current medications with the increase of Geodon with notable improvement. The patient is known to test limits on the unit and at times has become socially inappropriate. However, during this admission, the patient has refrained from such activity. The patient was very needy, quite demanding, and was focused on discharge.

After 4 days, the patient demonstrated improved insight and was not contracting for safety. Her affect was constricted. Her mood was irritable. Her thoughts were tangential. Appeared mildly sedated this morning and appropriate medication change was made. There were no overt delusions or hallucinations. Denies any suicidal ideation or homicidal ideation. At this time, the patient is stable for discharge.

Outpatient followup will include returning to group home as well as outpatient psychiatric medication management.

Prognosis is guarded given her history of repeated admissions and labile behavior.

Psychiatric Discharge Summary Sample Report #5



AXIS I: Schizophrenia, paranoid type, chronic, with acute exacerbation.
AXIS II: Antisocial personality disorder.
AXIS III: Crohn disease, chronic anemia, peptic ulcer disease, and possible gastrointestinal neoplasm.
AXIS IV: Severe.
AXIS V: 55.

REASON FOR ADMISSION: The patient is a (XX)-year-old Hispanic male admitted involuntarily because of hallucinations telling him to kill himself. This was one of many admissions for this man, who had a supposed history of schizophrenia, was noncompliant with any of his medications, sleeping on the streets, not eating, not sleeping, progressively becoming weaker, and finally experiencing auditory hallucinations that were telling him to kill himself. He reported being withdrawn, seclusive, and isolative with very depressed mood and anhedonia.

HOSPITAL COURSE: The patient was able to sign voluntary following admission. We started the patient on Risperdal 2 mg b.i.d., Cogentin 1 mg b.i.d., and Protonix 40 mg daily. Medical consultation was provided for the management of his various medical problems. After some blood work was done and a CT scan of the abdomen, it was felt that the patient was in need of a complete gastrointestinal workup in order to rule out gastrointestinal malignancy.

Mentally, the patient showed significant improvement, felt more animated and hopeful and was becoming less depressed. He, however, was doing poorly physically, and after discussing the case, we contacted Dr. John Doe in order to transfer him to the medical-psychiatric unit. Instead, he spoke with Dr. Jane Doe who felt that it would be indicated for the patient to be on the medical floor. Therefore, we discharged the patient to medical surgical bed to continue with his gastrointestinal workup.

CONDITION ON DISCHARGE: The patient was alert and oriented. Sensorium was clear. Speech coherent. Mood was much less depressed with brighter affect. No evidence of psychotic symptoms at this point. He denied auditory or visual hallucinations. Denies suicidal or homicidal ideas. Insight and judgment were both very limited.

LABORATORY DATA: His RPR was nonreactive. CBC showed a WBC of 6000, hemoglobin 12.6, and hematocrit 36.2. Chemistry profile was unremarkable. TSH 1.0. Urine toxicology was negative. Urinalysis was negative. A CT scan of the abdomen showed thickening of the cecal wall showing interval increase from the prior study and soft tissue density occupying the proximal ascending colon. They felt that this was a worrisome finding that could indicate a neoplastic process representing either cancer, lymphoma or a granulomatous lesion.


DIET: Regular.

ACTIVITY: As tolerated.

1. Cogentin 1 mg b.i.d.
2. Risperdal 2 mg b.i.d.
3. Pepcid 20 mg b.i.d.
4. Protonix 40 mg daily.
5. Ferrous sulfate 300 mg t.i.d.
6. Reglan 10 mg a.c.

FOLLOWUP: Follow up with Dr. Jane Doe on the medical floor for further workup and Dr. John Doe will continue psychiatric followup.