Reference no: EM133788133

PSYCHIATRIC HISTORY:
Keep it brief but significant

PROCEDURES AND TREATMENT:
1. Individual and group psychotherapy. - BE SPECIFIC
2. Psychopharmacologic management. - BE SPECIFIC
3. The social work department conducted family therapy with the patient and the patient's family for 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 actions taken on behalf of the patient, results (medication trials; responses/ diagnostics, treatments)

DISCHARGE ASSESSMENT:
At discharge, the patient is alert and fully oriented. Mood euthymic. Affect a broad range. He denies any suicidal or homicidal ideation. IQ is at baseline. Memory is intact-insight and judgment are good.

ASSETS and LIABILITIES:
This is strengths/weaknesses/support system/Maslow.

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 to himself or others. The patient will continue 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 the date of discharge was 110. The 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