Proper Format for Psychiatry Patient Discharge Note?

[prominence]

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what information must/should be included?

 

[Anasazi23]

LOL...I see they have you knee deep in psychiatric paperwork. You can thank the lawyers...

Anyway, we use the standard medical discharge summary sheets. Other more fortunate folks can dictate their summaries. Either way, this is the example we use:

1. Final diagnoses. List them all, for billing purposes..even things like BPH. 🙄

2. Case formulation and relevant initial findings. (This is basically a rounds-type presentation that is short and summarized).

3. Hospital course, including any significant labs, imaging results or procedures. Again, all used for billing.

4. Follow up. This will include everything from diet, activity level, to medications the patient was d/c'd with, and appt's made for follow-up.

 

[poonamnpatil]

Pls provide more info and links on case formulation.........................

 

[poonamnpatil]

also on conceptual diagnosis.................