Discharge / Transfer Summary Note

━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━ OUTPATIENT PSYCHIATRIC [DISCHARGE / TRANSFER] SUMMARY ━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━━ DOCUMENT TYPE: [Discharge Summary / Transfer Summary] DATE PREPARED: [MM/DD/YYYY] PREPARED BY: [Provider Name, Credentials] PRACTICE: [Practice Name, Address, Phone, Fax] NPI: [Provider NPI] | DEA: [If applicable] ───────────────────────────────────────────────────── PATIENT: [Full Name] DOB: [MM/DD/YYYY] | MRN: [___] DATE OF FIRST VISIT: [MM/DD/YYYY] DATE OF LAST VISIT: [MM/DD/YYYY] TOTAL VISITS: [##] | TREATMENT DURATION: [## months] RECEIVING PROVIDER (Transfer): Name: [Full Name, Credentials] Practice: [Practice Name] Phone/Fax: [___] Records sent: [Electronically / Fax / Secure email — date: ___] Patient consent to release: [Y — date: ___]

REASON FOR DISCHARGE / TRANSFER: [ SELECT APPLICABLE — DELETE OTHERS ] // PLANNED DISCHARGE: [ ] Treatment goals achieved — patient meets criteria for discharge Criteria met: [Symptom remission / Stable on regimen / Sustained improvement] [ ] Step-down to lower level of care Patient stable for: [PCP management / Community mental health] [ ] Transfer to higher level of care Reason: [Inadequate response / Safety concerns / Complex needs] [ ] Geographical transfer Patient relocating to: [City, State] [ ] Provider-initiated transfer Reason: [Practice closure / Provider departure / Outside scope] [ ] Patient-initiated discharge Reason per patient: [___] Provider recommendation: [Continued treatment recommended / Patient agrees] [ ] Administrative discharge Reason: [Non-attendance / Insurance loss / Safety concerns] // Handle death of patient with extreme care

TREATMENT COURSE SUMMARY: [Patient name] presented for initial psychiatric evaluation on [date] Treatment provided from [start date] to [end date], totaling [##] visits PRESENTING PROBLEMS AT INTAKE: [Brief summary of symptoms at intake] Initial PHQ-9: [___] Initial GAD-7: [___] TREATMENT PROVIDED: Medication management: [Y] Psychotherapy: [N/A / Type: ___] Care coordination: [PCP collaboration: Y/N] MEDICATION HISTORY: Drug | Dose Range | Duration | Response | Reason Stopped ---------------|------------|----------|---------------|---------------- [Drug 1] | [range] | [## mo] | [Good/Partial]| [Still taking] [Drug 2] | [range] | [## mo] | [___] | [Side effects] SIGNIFICANT EVENTS: [ ] No significant events [ ] Psychiatric hospitalization: [Date, facility] [ ] ER visit: [Date, reason] [ ] Crisis intervention: [___]

FINAL DIAGNOSES: [ PRIMARY PSYCHIATRIC ] 1. [ICD-10] [Full DSM-5-TR Diagnosis] Status: [In remission / Improved / Stable] 2. [ICD-10] [Diagnosis] Status: [___] [ SUBSTANCE USE ] [ICD-10] [Diagnosis — In remission / Active] [ MEDICAL CONDITIONS ] [ICD-10] [Medical condition — managed by: ___] [ RULED OUT / DEFERRED ] [Diagnosis ruled out — rationale: ___] [Diagnosis deferred — recommend reassessment]

MEDICATION RECONCILIATION: [ DISCHARGE MEDICATION LIST ] Medication | Dose | Frequency | Prescriber | Indication ---------------|---------|-----------|---------------|------------ [Drug 1] | [dose] | [freq] | [PCP/This] | [Dx] [Drug 2] | [dose] | [freq] | [___] | [Dx] OTC: [___] [ MEDICATIONS DISCONTINUED ] [Drug — reason: ___] [ MEDICATIONS REQUIRING MONITORING ] [Drug — monitoring: lithium levels / CBC — due: date] [ CONTROLLED SUBSTANCES ] [ ] No controlled substances [ ] Controlled substances: [Drug, Schedule, Dose, Qty] PDMP last checked: [Date] Bridge supply: [Days: ___]

RESPONSE TO TREATMENT: GLOBAL RESPONSE: [ ] Full remission [ ] Partial response [ ] Minimal response [ ] No response [ ] Unable to assess SYMPTOM OUTCOMES: PHQ-9: Baseline [___] → Final [___] = Change [+/-##] GAD-7: Baseline [___] → Final [___] = Change [+/-##] FUNCTIONAL OUTCOMES: Work/school: [Returned to work / Improved / Continued impaired] Relationships: [Improved / Stable / Difficulties] Self-care: [Independent / Improved / Impairment] ADHERENCE: [Generally adherent / Variable / Non-adherent]

RESIDUAL SYMPTOMS: [ ] No significant residual symptoms — full remission [ ] Residual symptoms present: Symptoms: [Mild sleep disturbance / Occasional anxiety] Severity: [Mild / Not functionally impairing] Clinical judgment: [Appropriate for discharge because: ___] UNRESOLVED QUESTIONS: [ ] None [ ] Recommend reassessment for: [___] RELAPSE WARNING SIGNS: [List signs for next provider to monitor]

RISK ASSESSMENT AT DISCHARGE: SUICIDAL IDEATION: [None] Since last visit: [No SI / Resolved since: ___] Last SI episode: [Date / Never] Current intent: [None] Access to means: [Firearms secured / No access] SELF-HARM: [None] HOMICIDAL IDEATION: [None] RISK FACTORS: [List ongoing risk factors] PROTECTIVE FACTORS: [Engaged in aftercare / Strong support / Future orientation] DISCHARGE RISK LEVEL: [Low] CLINICAL REASONING: [Patient appropriate for discharge because: sustained remission, strong support, no active SI, safety plan in place]

SAFETY PLAN AT DISCHARGE: Safety plan: [Completed / Reviewed] Validity: [Patient confirms current and relevant] SAFETY PLAN ELEMENTS: 1. Warning signs: [Patient-specific signs] 2. Internal coping: [What patient does alone] 3. Social support: [Name, phone] 4. Professional: [Receiving provider, phone] 5. Crisis resources: • 988 Suicide & Crisis Lifeline • Crisis Text Line: Text HOME to 741741 • Local ER: [Hospital] • 911 6. Means restriction: [Firearms: ___] [Meds: ___] COPY PROVIDED TO: [Patient / Family] Copy in chart: [Yes]

AFTERCARE PLAN: [ PSYCHIATRIC CARE ] [ ] No further care needed — discharged to PCP [ ] Transfer to: Provider: [Name] First appointment: [Confirmed — Date: ___] Records transmitted: [Y — date: ___] Warm handoff: [Y — spoke with: ___] [ THERAPY ] [ ] Ongoing with: [Name] [ ] Referred for: [CBT / DBT / Other] Appointment: [Confirmed: ___] [ PRIMARY CARE ] PCP: [Name] PCP notified: [Y — date: ___] Medications to be managed by PCP: [List] [ COMMUNITY RESOURCES ] [Support groups / 988 / Other: ___] CONFIRMED APPOINTMENTS: Provider | Date | Purpose ------------------|---------------|------------------ [Receiving prov] | [Date] | [Initial eval]

PRESCRIPTIONS AT DISCHARGE: [ ] No new prescriptions — managed by receiving/PCP [ ] Prescriptions provided: Drug | Dose | Qty | Days | Refills --------------|---------|-----|------|-------- [Drug 1] | [dose] | [##]| [##] | [#] BRIDGE SUPPLY: [## days supply provided until appointment on [date]] CONTROLLED SUBSTANCES: [ ] None [ ] Written — PDMP checked [date] NALOXONE: [Prescribed / Confirmed has supply / Not indicated]

PATIENT EDUCATION: [ DIAGNOSIS ] [ ] Nature of [diagnosis] [ ] Relapse warning signs [ ] Risk factors [ MEDICATIONS ] [ ] Importance of adherence [ ] Not stopping abruptly [ ] Side effects to watch for [ ] Drug interactions [ RESOURCES ] [ ] NAMI: nami.org / 1-800-950-NAMI [ ] 988 Suicide & Crisis Lifeline [ ] Medication list provided [ ] Safety plan provided UNDERSTANDING DEMONSTRATED BY: [Asking questions / Restating key points / Verbal confirmation]

EMERGENCY INSTRUCTIONS: Patient instructed to seek IMMEDIATE care (call 911 or go to ER) for: PSYCHIATRIC: • Active suicidal ideation with plan/intent • Active homicidal ideation • Severe psychosis • Acute manic episode with dangerousness MEDICATION: • Suspected overdose • Serotonin syndrome: fever, rapid HR, rigidity • Severe allergic reaction / rash • Lithium toxicity symptoms • New seizure CRISIS RESOURCES: • 988 Suicide & Crisis Lifeline • Crisis Text Line: Text HOME to 741741 • Local ER: [Hospital, address, phone] PATIENT CONFIRMED UNDERSTANDING: [Yes] EMERGENCY CONTACTS: Primary: [Name, relationship, phone] Patient consented to emergency contact: [Y]

PROVIDER COMMUNICATION: [ RECORDS TRANSMITTED ] [ ] Discharge summary [ ] Complete psychiatric records [ ] Medication list [ ] Safety plan Method: [Fax / Secure email / EHR] Date sent: [___] Confirmation: [Y/N] [ VERBAL COMMUNICATION ] [ ] No phone contact [ ] Warm handoff call with [Provider]: Date: [___] Discussed: [Diagnoses / Meds / Risk / Concerns] Next appointment: [Confirmed: ___]

PROVIDER ATTESTATION: I attest that this discharge summary accurately reflects the care provided to [Patient Name] during the treatment period [dates]. ATTESTATION: Prepared by: [Name, Credentials] Date: [MM/DD/YYYY] Signature: _______________________________ SUPERVISION (if applicable): Supervising physician: [Name, MD/DO] Reviewed and agreed: [Y — date: ___]

DISCHARGE CHECKLIST: REQUIRED ELEMENTS: [ ] Reason for discharge documented [ ] Treatment course summarized [ ] Final diagnoses with ICD-10 [ ] Medication reconciliation complete [ ] Response to treatment documented [ ] Residual symptoms documented [ ] Risk assessment at discharge [ ] Clinical reasoning for discharge safety [ ] Safety plan current and documented [ ] Aftercare plan with confirmed appointments [ ] Prescriptions at discharge documented [ ] Patient education documented [ ] Emergency instructions provided [ ] Provider attestation completed TRANSFER ITEMS (if applicable): [ ] Receiving provider identified [ ] Records transmitted [ ] Warm handoff completed [ ] Patient consent to release on file [ ] Controlled substances addressed [ ] Bridge prescriptions provided