Discharge summary for psychiatric patient

GingerSue · Sep 12, 2007

this is from a comprehensive mental health assessment in a textbook of a few years ago:

A. Life functions

1. Physical Health

Current medical care (family physical or medical clinic, medications)

2. Self-Acceptance/Self-Esteem

3. Vocational/Occupational

(employed/school)

4. Immediate Family

5. Intimate Relationships

6. Residential

(living situation)

Significant Other Information

7. Financial

(source of income)

8. Decision Making/Cognitive Functions

9. Life Philosophy/Goals

10. Leisure Time/Community Involvement

11. Feeling management

B. Signals of Distress

12. Lethality (self)

(history of self-injury, method, within last month, within, last 6 months, last year, over 1 year ago, high lethal, low lethal, outcome, total number of suicide attempts, date of last attempt)

13. Lethality - other

(history of injury to other, method, within last month, etc, outcome,

total number of assaults, date of last assault)

14. Substance use (drug and/or alcohol)

(other drug use: type, present use, past use, duration)

15. Legal

(pending court action, on probation, on parole, conditional discharge, where, when, probation officer, parole officer, judge)

16. Agency Use

(previous mental health service contacts: outcare: name of agency, phone #, contact person, address, date of last contact

incare: same info, reason for admission, how often, how long, average length of stay)

17. Optional information (religious concerns, ethnic cultural background problems)

hope this is some help

Boston64 · Sep 12, 2007

Hi! Gingersue,

Thanks, so much, for your reply!! This information will be extremely helpful!!

Boston64