This page was last
revised by Karen Brown
on 6/12/05
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Improving Mental Health Information Programme Draft (inpatient / day case) Discharge Summary |
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CHI Number |
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| Principal treating hospital patient number |
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| GMC number of GP for correspondence | |
| GP for correspondence (details) | |
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GP Practice code
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| Service user details | |
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Family name/ surname
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First forename
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Second forename
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Preferred name
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Previous family name/ surname
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Date of birth
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Address
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Post code
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Address type
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Telephone number
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Telephone number type
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Internet E-mail address
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Current gender
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Ethnic group
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Preferred language
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Interpretation assistance
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Household composition
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Lives alone?
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Accomodation type
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Currently engaged in employment/ education/ voluntary work
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| Associated person(s) | |
| Associated person name | |
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Family name / surname
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First forename
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Second forename
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Preferred name
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Address
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Post code
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Address type
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Telephone number
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Telephone number type
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Internet E-mail address
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Associated person role
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Relationship to client/ patient
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Comments on relationship
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Age of associated person (if a child)
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| Admission/Transfer data | |
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Date of admission/ transfer
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Admission/ transfer reason
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Admission type
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Comments (admission)
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| Associated Professionals | |
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Role of clinician
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Grade of clinician
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Clinician: specialty
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Associated professional:identifier
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*recurring item |
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Associated professional: name
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Associated professional: family name/ surname
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Associated professional: first forename
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Associated professional:second forename
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Associated professional:preferred name
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Associated professional : address
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Post code
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Telephone number
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Telephone number type
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Internet E-mail address
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Associated professional group
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Associated professional role
Key Worker
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*recurring item (other associated professional role)
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| Legal Data | |
| Is the person subject to legal measures? | |
| If subject to legal
measures , which statute?
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| Risk Factors | |
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Has a formal risk assessment identified a specific risk?
Current risk
Risk history
Risk history comments
Known triggers
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| Current problem(s) | |
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Mental health problem/ symptom(s)
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Life/ Social difficulties
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| Recent parent | |
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Primary psychiatric diagnosis
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Certainty of diagnosis
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| Other psychiatric diagnoses | *recurring item |
| Certainty of diagnoses | |
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Physical health problems
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Impairment
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(other impairment) |
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Allergies, intollerances and adverse reactions
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Comments related to allergy, intollerance or adverse reaction
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Serverity of reaction
Comment related to problems/ diagnoses
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| Interventions | |
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Intervention
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Date of significant intervention
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| Comments on key interventions
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| Medication Data | |
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Current medication
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Medication history
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Prescribed items
Prescribed by:
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Start date
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Stop date
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- - *recurring item dd-mm-ccyy |
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Length of treatment
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Route of administration
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Prescribed item formulation
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Prescribed item dosage
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Prescribed item quantity
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Medication compliance assistance required
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Comments (medication history)
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Contra-indicated items
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Reason (contra-indicated items)
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| Discharge | |
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Ready for discharge date
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Date of discharge/ transfer
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- - dd-mm-ccyy |
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Date of death
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- - dd-mm-ccyy |
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Discharging hospital identifier
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Discharging hospital
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Discharging ward/ department
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Discharge/ Transfer to - location code
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Discharge/ Transfer to
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Discharge type
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Care programme approach
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CPA key worker name
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CPA key worker agency
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