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Mental Health Discharge Summary Sample

ID:DOB:4/30/19871000010668241 Nesmith, Kelly7/20/2017 Discharge Summarymedicaid ID:6 MRoom 1 of 7 PSYCHIATRIC CLINIC, LLC123 Main StreetAnywhere, US 12345-6789555-678-9100 (O)555-678-9111 (F)DATE ADMITTED: 4/24/2017 DATE DISCHARGED: 7/20/2017 This Discharge Summary consists of 1. Initial Assessment 2. Course in Treatment 3. Clinician's Narrative 4. Discharge Status and Instructions_____1. INITIAL ASSESSMENT4/26/2017 Complete Evaluation / PsychosocialHistory: Ms. Nesmith is a divorced Caucasian 29-year-old woman. Her chief complaint is, "I'mdepressed." Information Received From: Ms. Nesmith Ms. Nesmith's Family Depression History: Ms. Nesmith describes symptoms of a depressive disorder.

Has never received outpatient mental health treatment. Suicidal/Self Injurious: Ms. Nesmith has a history of suicidal thoughts but has never made an attempt. Assault History: Ms. Nesmith has been assaultive. She has been in fights but has never seriously injured anyone. Addiction/Use History: Ms. Nesmith has a history of possible alcohol over use.

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