Discharge Summary And Summary

Topic 8 Discharge Summary Template

Directions: Complete the Discharge Summary form by addressing the fields below.

right1088390Presenting Problem Upon Admission:

Eliza is a victim of major depressive disorder. She has been using alcohol excessively and accepts taking 3-4 drinks each day.

00 Presenting Problem Upon Admission:

Eliza is a victim of major depressive disorder. She has been using alcohol excessively and accepts taking 3-4 drinks each day.

Client Name: Eliza

Date of Birth: 03/19/2000

Date of Admission: 02/02/2019

Date of Discharge: 06/16/2019

03243580Resources and Referrals:

The resources for the treatment plan will be provided by parents including therapist fee.

The school will also be requested for supporting their student's treatment. The funds will be used for providing access to exercise and therapy materials.

Referral from the client's physician and psychologist will be considered before starting the exercise.

This is important for determining if Eliza is physically fit and capable of performing the exercise

00Resources and Referrals:

The resources for the treatment plan will be provided by parents including therapist fee.

The school will also be requested for supporting their student's treatment. The funds will be used for providing access to exercise and therapy materials.

Referral from the client's physician and psychologist will be considered before starting the exercise.

This is important for determining if Eliza is physically fit and capable of performing the exercise

right1571597Current Medication:

Medications used for treating Eliza include;

Anti-depressants like SSRI

It is administered depending on the need of the patient.

00Current Medication:

Medications used for treating Eliza include;

Anti-depressants like SSRI

It is administered depending on the need of the patient.

Reason for discharge

Improvement in behavior

The patient exhibits self-control.

Eliza exhibits determination and motivation for recovery.

0244475Projected Prognosis:

The signs and symptoms of the patient will improve.

Eliza exhibits signs of complete recovery within the period of the next three months.

00Projected Prognosis:

The signs and symptoms of the patient will improve.

Eliza exhibits signs of complete recovery within the period of the next three months.

Eliza D 00/00/00

<sign and date here>

Client Signature & Date

Case Manager Signature & Date

Part I

Health baseline

Certain behaviors are considered that reflects client is sustaining a healthy baseline. These behaviors include; positive attitude towards different situations such as the ability to overcome depression. The client will manage to control feelings of aggression or violence. The client will exhibit positive attitude towards counselling and is determined to overcome depression CITATION Fra11 \l 1033 (Desplenter, Laekeman, & Simoens, 2011). The behavior reflecting healthy baseline include reducing consumption of alcohol. NASAC standard 75 is used for identifying criteria for discharge.

Determination of treatment goals

Assessments will be conducted for identifying how treatment goals are working in case of Eliza. Set criteria will be considered for evaluating the treatment guidelines. The primary method will include comparing the progress of client with the goals. It will be determined if the patient is following the deadlines and instructions or not. The treatment goals will be evaluated by considering the performance and role of healthcare providers. Examining the condition of Eliza will depict if the providers met the criteria of treatment goals or not.

Evaluation of clinical settings

The factors that suggest a reevaluation of the treatment plan include; clinical settings failing to meet eligibility criteria, the inability of the therapist to work on the goals, client showing no signs of improvement. The absence of appropriate environment also encourage change in the treatment plan and clinical settings. Assessment is conducted by using the Global Assessment Scale (GAS) and Social Adjustment Scale Self-Report (SAS-SR). SAS-SR scale is utilized for determining the social perceptions of Eliza CITATION Car10 \l 1033 (Hughes, et al., 2010). The results that are non-satisfactory will suggest changing the settings.

Recommendations

The assessment of the client’s condition reflects that she needs wraparound services. A certified psychologist or therapist will develop an effective treatment plan including short-term and long-term goals. The plan will be communicated with all team members including the exercise trainer and therapist. Wraparound services will focus on conducting evaluations at regular intervals. The therapeutic support staff will reinforce appropriate strategies that will allow Eliza to adhere to the treatment plan. These services will assist the client by addressing her needs. it will focus on providing a safe environment of recovery.

Encouraging involvement

Another important part of the treatment plan is to encourage the involvement of Eliza in the recovery program. The therapist will make the client realize that she is part of the treatment plan and encourage her to take responsibility. Making the client part of a team provides encouragement for self-control. The therapist will talk about the client's capabilities such as her potential for dealing with negative situations and anger. This process will have a significant influence on the client's recovery CITATION Chr171 \l 1033 (Iliades, 2017). The therapist will adopt positive behavior and encourage Eliza to take part in discussions.

Part II

Assessment of goals relying on NASAC standard 73 depicts that there is a need for continuing treatment. Although the client exhibits some signs of progress she has not been able to overcome her addiction to substance completely. The signs of progress are apparent in her positive attitudes towards therapeutic sessions. The use of selective serotonin reuptake inhibitors (SSRI) helped Eliza in improving her sleep cycle CITATION Fra11 \l 1033 (Desplenter, Laekeman, & Simoens, 2011). The inhibitors assisted her in managing extreme depression and relax nerves. The client follows the exercise schedule and spends time on physical activity accordingly. During the session, the client shares her feelings of anxiety with the therapist that allow her to replace her negative feelings with hope. The overall assessment depicts that the client is following treatment goals.

The success of treatment plan depends on the behavior of Eliza. The client has managed to follow the instructions of the client as she reports spending quality time with her family. This has helped her in improving her relationship with her parents. The treatment plan has been successful because the goals focused on eliminating the distance between Eliza and her parents. Change in her behavior developed feelings of comfortability and positivity CITATION Chr171 \l 1033 (Iliades, 2017).

Language for communications used for sharing the treatment plan include both oral and verbal means. Written language is used in the documents and instruction sheets that explain the responsibility of the client. The therapist adopts a positive and encouraging tone during counselling sessions. This ensures that the sessions help Eliza in establishing self-control and problem-solving attitude CITATION Fra11 \l 1033 (Desplenter, Laekeman, & Simoens, 2011). The positive body language of the therapist also plays an effective role in promoting feelings of confidence, self-esteem and self-help. The therapist must adopt a polite style when he conveys information to the client.

The process of documentation will follow NASAC standard 74 that emphasize on recording case management activities. Documenting session is the final part of the process. It includes details about the treatment goals, duration and outcomes. A written document will be used that will identify all changes in the program. The therapist will obtain consent from Eliza before starting the treatment plan. NASAC standard 74 is followed for ensuring accurate documentation. The document contains the consent and signature of both the client and the therapist. This is important for complying with the ethical guidelines for treating depression. The purpose of creating a document is to keep a record of the sessions taking place between the patients and the therapist.

References

BIBLIOGRAPHY Desplenter, F. A., Laekeman, G. J., & Simoens, S. R. (2011). Following up with patients with depression after hospital discharge: a mixed methods approach. international Journal of Mental Health Systems, 5 (28).

Iliades, C. (2017). Adjusting Your Depression Treatment Plan. Retrieved 03 20, 2019, from https://www.everydayhealth.com/hs/major-depression/adjusting-depression-treatment-plan/

Hughes, C. W., Trivedi, M. H., Cleaver, J., Greer, T. L., Emslie, G. J., Kennard, B., et al. (2010). DATE: Depressed adolescents treated with exercise: Study rationale and design for a pilot study. Ment Health Phys Ac, 2 (2), 76–85.