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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 the discharge of your 46-year-old
female patient, admitted on 22/05/2019 due to substance dependence disorder. Upon
admission, a comprehensive psychiatric and somatic assessment was performed, including
structured diagnostic interviews, laboratory screening, and toxicological analysis,
confirming polysubstance dependence (ICD-10: F19.2). During her inpatient stay, the
patient underwent medically supervised detoxification with pharmacological support
to manage withdrawal symptoms. Motivational interviewing and psychoeducational sessions
were conducted. The patient was stabilised successfully without major complications.
At discharge, she was referred to an outpatient addiction counselling service and
a community support programme. Relapse prevention strategies were discussed thoroughly.
I kindly ask you to continue monitoring her mental and physical health and support
adherence to the outpatient treatment plan. Please do not hesitate to contact me should
any concerns arise.
Diagnosis at Discharge
| Mental and behavioural disorders due to multiple drug use – dependence syndrome | 31-May-2019 | active |
Significant procedures
| Referral to outpatient addiction services | 30-May-2019 | - |