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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 regarding your patient, a 34-year-old male,
admitted on 25/01/2016 following presentation with substance dependence disorder.
On admission, a comprehensive psychiatric and somatic assessment was performed, including
toxicological screening, which confirmed poly-substance dependence. During his brief
inpatient stay, the patient underwent medically supervised detoxification with symptomatic
pharmacological support to manage withdrawal symptoms. Psychological counselling and
motivational interviewing were initiated. The patient was stabilised without major
complications and discharged on 26/01/2016 with a diagnosis of ICD-10 F19.2. We strongly
recommend outpatient follow-up with addiction medicine services, continuation of psychosocial
support, and referral to a structured rehabilitation programme. Please do not hesitate
to contact our department should further information be required. Yours sincerely,
Dr. [Treating Physician], Department of Psychiatry and Addiction Medicine
Diagnosis at Discharge
| Mental and behavioural disorders due to multiple drug use – dependence syndrome | 26-Jan-2016 | active |
Significant procedures
| Referral to outpatient addiction rehabilitation | 26-Jan-2016 | - |