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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 regarding our mutual patient, a 39-year-old male admitted
on 28/12/2015 due to substance dependence. Upon admission, a comprehensive psychiatric
and medical assessment was conducted, confirming polysubstance dependence syndrome.
Urine toxicology screening was positive for multiple substances. The patient underwent
structured detoxification with pharmacological support to manage withdrawal symptoms,
including monitoring for autonomic instability. Psychological counselling and motivational
interviewing sessions were initiated during the inpatient stay. The patient was stabilised
without major complications and discharged on 30/12/2015 in a clinically improved
condition. We strongly recommend follow-up with addiction medicine services and continuation
of psychosocial support in the community setting. Please do not hesitate to contact
me should you require further information. 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 | 30-Dec-2015 | active |
Significant procedures
| Discharge planning and community referral coordination | 30-Dec-2015 | - |