Discuss all action taken on behalf of the patient, results.

Discuss all action taken on behalf of the patient, results.

PROCEDURES AND TREATMENT:
1.  Individual and group psychotherapy. – BE SPECIFIC
2.  Psychopharmacologic management. – BE SPECIFIC
3.  Family therapy conducted by social work department with the patient and the patient’s family for the purpose of education and discharge planning.
HOSPITAL COURSE:  Brief discussion of hospitalization – how things went. The patient responded well to individual and group psychotherapy, milieu therapy and medication management.  As stated, family therapy was conducted. – HOW DID THESE ALL GO?; Discuss all action taken on behalf of the patient, results (medication trials; responses/ diagnostics, treatments)

DISCHARGE ASSESSMENT:  At the time of discharge, the patient is alert and fully oriented.  Mood euthymic.  Affect broad range.  He denies any suicidal or homicidal ideation.  IQ is at baseline.  Memory intact.  Insight and judgment good.
ASSETS and LIABILITIES: this is strengths/weaknesses/support system/Mazlow

SHORT TERM GOALS and LONG TERM GOALS: determined by staff with patient input, address each goal and progress toward that goal

DISCHARGE PLAN:  The patient may be discharged as he no longer poses a risk of harm towards himself or others.  The patient will continue on the following medications; Ritalin LA 60 mg q.a.m., Depakote 500 mg q.a.m. and 750 mg q.h.s., Abilify 20 mg q.h.s.  Depakote level on date of discharge was 110.  Liver enzymes drawn were within normal limits.  The patient will follow up with Dr. Doe for medication management and Dr. Smith for psychotherapy.  All other discharge orders per the psychiatrist, as arranged by social work. Any other treatment recommendations