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Hospital Discharge Report
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Synthesis
Substance dependence, treated and stabilised
Hospital course note
Dear colleague, I am writing to inform you about the inpatient treatment of your 35-year-old
male patient, admitted on 14/09/2024 and discharged on 21/09/2024 due to substance
dependence disorder. Upon admission, a comprehensive psychiatric and somatic assessment
was performed, confirming polysubstance dependence (ICD-10: F19.2), primarily involving
opioids, benzodiazepines and cannabis. Urine drug screening was positive for multiple
substances. We initiated a structured detoxification protocol with supervised pharmacological
withdrawal management, including symptomatic treatment. Psychoeducational sessions
and motivational interviewing were conducted throughout the stay. The patient was
stabilised without significant medical complications. We strongly recommend referral
to an outpatient addiction counselling service and continuation of psychosocial support.
A follow-up appointment in your practice within two weeks is advised. Should you require
further information, please do not hesitate to contact us.
Diagnosis at Discharge
| Mental and behavioural disorders due to multiple drug use – dependence syndrome | 21-Sep-2024 | active |
Significant procedures
| Discharge planning and aftercare coordination | 20-Sep-2024 | - |