HTML Preview Psychiatric Facility Discharge Summary page number 1.
MONTANA STATE HOSPITAL
FORENSIC MENTAL HEALTH FACILITY
POLICY AND PROCEDURE
DISCHARGE SUMMARY FOR PATIENTS AT
THE FORENSIC MENTAL HEALTH FACILITY
Effective Date: February 1, 2016 Policy #: MSH FMHF-14
Page 1 of 3
I. PURPOSE: To provide guidelines for the completion of discharge summaries.
II. POLICY:
A. The discharge summary provides a synopsis of the patient’s history and their
examination, care, and treatment at the Montana State Hospital (MSH) Forensic
Mental Health Facility (FMHF). The basis for the discharge summary is the patient’s
clinical assessments, treatment plan, progress notes, and treatment plan reviews.
B. A discharge summary is to be entered into the patient record within thirty (30) days
following discharge.
III. DEFINITIONS: None
IV. RESPONSIBILITIES:
A. The attending Licensed Independent Practitioner (LIP) or a designee is responsible
for completing the discharge summary.
V. PROCEDURE:
A. The discharge summary will be written by a member of the hospital’s professional
staff who is well acquainted with the patient’s clinical course during their stay at the
FMHF. The summary must be approved and signed off by the attending LIP.
B. The discharge summary will contain the following information:
1. Identifying data – patient’s name, hospital number, date of admission, and
discharge date.
2. History of present illness – includes reason for admission and pertinent history,
which may include psychiatric, drug and alcohol, family, medical, social, work,
marital/children, military service, and criminal histories, and living situation.