peer review discharge planning

Name: R.F.

Client level of care at time of discharge: Outpatient

                                                           

Admission Date: 08/05/2022

Date of Discharge: 01/25/2023

 

Type of Discharge (Pick one):

 Collaborative Discharge: The ASO/CS, Employment Specialist and Client all agree that the services are no longer medically necessary, and the client has successfully completed the program.  

 Individuals Discontinuation of Services: The client has decided to discontinue services prior to a planned collaborative discharge.

 Program Recommendation to Discontinue Services: Due to client’s actions or request, services are no longer appropriate as determined by the Employment Specialist and Program Director.

Psychiatric History:

Major depressive disorder, recurrent, mild [ICD-10: F33.0], [ICD-9: 296.31], [SNOMED: 40379007]

Primary insomnia [ICD-10: F51.01], [ICD-9: 307.42], [SNOMED: 3972004]

Generalized anxiety disorder [ICD-10: F41.1], [ICD-9: 300.02], [SNOMED: 21897009]

Summary of reason for discharge: Effective immediately, and as per the client's request, no further psychiatric follow ups or medication management services will be provided through this office/ provider.

 

Discharge Assessment:  At the time of discharge, the patient is alert and fully oriented. He denies any suicidal or homicidal ideation.

 

Recommendations/referrals for continued treatment and community supports: Patient should seek another outpatient clinic that can continue following him. Patient advised to call my office or return to the emergency department if he begins to feel overwhelmed, depressed and or suicidal again. He is advised to see Dr. H for psychological counseling. Dietary counseling advised as well. Patient advised to seek outpatient therapy for continued support.