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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 of the discharge of your 46-year-old female
patient, admitted on 14th September 2021 due to substance dependence disorder. Upon
admission, a comprehensive psychiatric and somatic assessment was conducted, including
structured clinical interviews, toxicological screening, and physical examination,
confirming multiple substance dependence (ICD-10: F19.2). During her brief inpatient
stay, the patient underwent medically supervised detoxification with pharmacological
support to manage withdrawal symptoms. Motivational counselling sessions were initiated
alongside psychoeducation regarding substance use risks and relapse prevention strategies.
At discharge on 15th September 2021, the patient was clinically stabilised, motivated
for continued abstinence, and referred to outpatient addiction counselling. We recommend
close follow-up, ongoing psychological support, and monitoring of potential comorbidities.
Please do not hesitate to contact us should further information be required.
Diagnosis at Discharge
| Mental and behavioural disorders due to multiple drug use – dependence syndrome | 15-Sep-2021 | active |
Significant procedures
| Referral to outpatient addiction counselling | 15-Sep-2021 | - |