Suggested headings for psychiatry discharge summaries

(Modifiable for clerkings, case reports, etc.)

The discharge summary is potentially a very important and useful document. It may be referred to years later and it should be possible to gain a good idea of the patient's mental state and the degree of support for the diagnosis reached. It should also be helpful as a record of responses to different therapeutic interventions. The Part I summary should be completed within a week or two of admission (when it is easiest to do anyway) and can then serve as a useful summary for anyone called to see the patient, and as a basis for any reports which may need to be prepared. The Part II summary (which actually requires very little work once the Part I is completed) should be done within a week or two of discharge.

Organising the information in a psychiatric history and mental state examination can be quite difficult, but I hope the suggestions below may be of some use.

Dave Curtis, April 2011

Part I summary


Mode of referral / Presenting complaint

Provide a sentence or two explaining how the patient came to access services on this occasion. Include admission status.

History of present condition

Fairly full account of development of current episode of illness in chronological order. If there are things which will be described later in detail under Mental State Examination then only brief summary need be given here, e.g. "worsening depression with biological features", "many persecutory and grandiose delusions".

It is important that this section provides an account of the time course of the presenting problem(s). If necessary bring together information obtained from a variety of sources and reorganised into chronological order. (If there are any physical symptoms that are volunteered or discovered on systematic enquiry, an account of these should also be given here.) Also document here all attempts at treatment of the current disorder, including effectiveness and side effects. Be sure to include any psychological treatments. Also document here interventions which form part of the Care Program Approach, such as support from a Community Mental Health Nurse and day centre attendance.

Drug history

Medication the patient is taking or should be taking, with rough duration.

Past psychiatric history

Include timing, rough length and whereabouts of past admissions. Find out past treatments and response to them, in particular ECT, lithium, depot neuroleptics. Make sure to get history of any self-harm and record it even as a negative, and of violence to others. Find out about previous out-patient or general practice treatment. It is very easy to miss past and present counselling/psychotherapy (many people presenting in a crisis seem to deliberately omit mention of this) so ask about it specifically.

Past medical history

Significant illnesses, operations.

Family history

Parents' occupations, age now/at death. (Be aware of age of patient when bereaved.) Approximate quality of relationship with each other and patient. Any other notable features, e.g. serious illness. Numbers and ages of siblings with brief account of their social adjustment, relationship with patient. Presence and nature of any known psychiatric illness or alcohol abuse in any first or second degree relatives.

Personal history

Life history from birth until present, including geographical information. Birth, childhood. (Include milestones and "neurotic traits" if you want to.) How got on at schools: socially, academically, athletically. Age finished education and qualifications obtained. Occupational history - some account of number/nature/duration of jobs, maybe reasons for leaving, etc. Psychosexual history - orientation, first SI, number/length of longest/most recent relationship, etc. Enquire about childhood sexual abuse. Number of children, with sex, age and parentage of each.

Forensic history

Convictions, sentences. Also include here any history of violent behaviour which may not have resulted in a criminal conviction.

Social history

Where living and with whom, income, social support. Contact with children. Alcohol, tobacco, other recreational drugs.

Premorbid personality

Or if chronic illness then best functioning when not acutely unwell. Interests, recreations, activities. Degree of sociability. Obsessional/anxious/depressive traits.

Mental state examination


Cleanliness, grooming, dress, size, apparent age, etc. Obvious physical signs such as tremor, goitre, ptosis.


Rapport. Degree of cooperation. Motility, gestures, disinhibition.


Rate, volume, quantity, fluency. Any accent, dysarthria, problems with language. Use of obscenities. Mention briefly gross thought disorder, neologisms, obvious dysphasia. Uninterruptible?


Subjective mood over last days/weeks. Variability of mood. Energy, enjoyment, interest, anhedonia? Reports being tearful? Recent and current suicidal intent. Biological features of affective disorder: appetite, weight, sleep (initial/middle/terminal insomnia), diurnal mood variation, libido, constipation.


Impression of mood conveyed to observer ("objectively") by facial expressions, etc. Ever smiles, cries? Appropriateness, lability.

Thought form

(Abnormalities of stream usually included here.) Loosening of associations, derailment, neologisms, punning, clang associations, etc. Appropriateness of answers. Subjective rate, quantity, experience of thought block. Poverty of content?

Thought content

Include passivity experiences and thought insertion, broadcasting, withdrawal. Delusions, over-valued ideas. Depressive cognitions consisting of low self-esteem, guilt, hopelessness. Grandiosity. Preoccupations, obsessions. Traditionally compulsive behaviours, panic attacks and anxiety-related symptoms are often described here.


Hallucinations, illusions. Describe modality and nature, taking particular care in relation to possible first-rank symptoms. Put depersonalisation here.


If nothing else, apparent level of consciousness. Orientation. Concentration, attention (digit span, serial sevens). Short term memory (name and address, recent events). Further testing when indicated for: naming/comprehension difficulties, constructional apraxia, dysgraphia, left-right orientation, verbal fluency, sensory/visual inattention, perseveration, astereognosis. May include subjective estimate of approximate intelligence.


Patient's view of diagnosis and aetiology. Extent of compliance with treatment plans.

Physical examination

Findings on admission.

Part II summary


Investigations performed and results.

Treatment and progress

Account of response to treatment interventions contained in a few sentences describing course of admission. Other developments during the course of admission should also be documented here.

Final diagnosis

All applicable diagnoses with ICD10 codes, including for concomitant physical disorders.

Medication on discharge

List all medications, including for physical conditions, along with doses.

Follow-up arrangements

Identities and roles of professionals who will be involved with aftercare, CPA status and name of care coordinator.


A sentence or two about the likely future course, often with a note about the dependence of the prognosis on the patient's compliance with treatment.


There are a number of ways of organising the necessary information, above is one suggestion that is fairly widely used. However be aware (for exams, etc.) that other people may use different schemes.

Some people use mood and affect to mean "climate and weather". The mood is the major pervasive emotional state, with the affect being more or less changeable around this "average". In any event I think both subjective and objective descriptions should be noted. (Tend to avoid using the term "depressed" descriptively, as it relates to a particular diagnosis.)

One fairly commonly used scheme places the past psychiatric history almost last. I think this is silly and that it should be presented early on. This can save the reader/listener a lot of unnecessary distraction while they try to weigh up different possible diagnoses based on just the acute presentation. In some patients it will be appropriate to incorporate the past psychiatric history into the history of the present condition, afer a brief account of the mode of presentation.

The biological and cognitive features of depression should always be noted, even as negatives. Logically, one might well put the biological features in the history of the present condition. Some people have a separate heading in the history called habits, which includes sleep, appetite, smoking, drinking, drug use, etc.

Recent and current suicidal intent must be noted somewhere. Conventionally it often goes under mood. Logically it could go under thought content, along with depressive cognitions.

It can be difficult to make a distinction between speech and thought form, and it might be allowable to subsume both under one heading (probably speech), provided all the features mentioned are included. However there are subjective aspects to thought, such as rate and the experience of block, which are not necessarily apparent in speech and need to be specifically enquired about.

In general mental state abnormalities should be described as objectively as possible with verbatim examples, rather than just giving the category of phenomenon they fall into. For example rather than say "he had thought-broadcasting..." say "he displayed thought-broadcasting, in that he believed the CIA could read his mind with a special computer". This means the reader can decide for himself what category the phenomenon falls into (in my view, the above would not be thought-broadcasting). Without examples, the reader is forced to rely on your judgement. This applies particularly to psychotic symptoms, including thought disorder and neologisms, and especially to first-rank symptoms which have diagnostic importance and are easy to get wrong. This does not mean that you should write down all abnormalities you elicit, just a clear example or two for each category.

Some authors write of four kinds of abnormality of thought: form, stream, content and possession. As you can see, I have subsumed these into the two main ones of form and content.

If there is any suggestion of high alcohol intake or alcohol-related problems then a separate heading of alcohol history should be given. This should contain quantity and pattern of present drinking, withdrawal symptoms, history of fits, DT's, blackouts, alcohol-related problems (physical/psychological/social), lifetime history of intake including previous dry periods, and perhaps family attitudes to drinking. It is crucial to include mention of morning withdrawal symptoms (shakiness, sweatiness, nausea) since these indicate physical dependency and the necessity for controlled detoxification (to avoid DT's and/or fits).

In the past and family psychiatric history, it is worth bearing in mind that one can usually make a very good stab at a diagnosis just by knowing the number and length of admissions, perhaps with some idea of the level of functioning in between. Of course, this isn't the actual diagnosis, just what somebody else thinks is the diagnosis. Thus somebody who has several very brief admissions is not thought to have major affective disorder, and somebody who has a few long admissions and is maintained on injections in between is probably thought to be schizophrenic, and so on.

For student case reports the discussion about differential diagnosis and aetiology would need to be expanded, and the account of the treatment would include an explanation of the aims of each intervention, and perhaps also a consideration of other treatments which might have been used but which were not.

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