Mental Health Post-Discharge Follow-up
Patient Information
Name
Date of Birth
Medical Record Number
Discharge Details
Date of Discharge
Primary Diagnosis
Medications Prescribed
Follow-up Information
Follow-up Date
Follow-up Time
Location/Mode (in-person, phone, video)
Clinician Assigned
Current Mental State
Summary of Mental Status
Risk Assessment
Suicide/Self-harm/Harm to Others
Medication Adherence
Is the patient taking medication as prescribed?
Yes
No
Uncertain
Support & Social Situation
Support System & Social Situation
Interventions and Advice
Interventions/Advice Given
Next Steps
Plan/Recommendations/Referrals