Psychiatric hospitalisation report: template, outline and example

A psychiatric hospitalisation report (compte rendu d'hospitalisation) is the medical document that covers a full inpatient stay in a psychiatric unit, from admission to discharge. It sets out the reason for admission, the legal status of the stay, the clinical course, treatments, investigations and the follow-up plan. It is more detailed than the liaison letter handed to the patient on the day of discharge, and it serves as the memory of the stay in the patient record.

This page is for psychiatrists and residents working in French hospitals, including doctors trained abroad who are new to French documentation rules. It covers the difference with the discharge liaison letter, the legal framework, a section-by-section outline and a filled-in example with a fictional patient.

Hospitalisation report or discharge liaison letter?

The two documents are often mixed up. They do not have the same status or the same reader.

The discharge liaison letter (lettre de liaison) is a regulatory requirement. Decree no. 2016-995 of 20 July 2016 created article R. 1112-1-2 of the French Public Health Code. The hospital doctor who treated the patient writes it. It is handed to the patient on the day of discharge and sent the same day to the GP (médecin traitant) and, where relevant, to the referring doctor, through secure messaging or another confidential channel. It is added to the shared medical record (DMP) if one exists. The decree lists its content (identification, reason for admission, medical summary of the stay, discharge medication, pending results, next steps).

The hospitalisation report is a fuller document written for the record. The same decree replaced the reference to the hospitalisation report with the liaison letter in the list of record contents in article R. 1112-2. Many units still write a detailed report, sometimes a few days after discharge. It tells the story of the stay, the decisions taken and why. It is read by teams who will see the patient again, by the community psychiatrist and by the patient if they ask for their record.

Put simply, the liaison letter tells the GP what they need to know and do from tomorrow. The report tells the story of the stay for whoever needs it later. For the liaison letter, use our psychiatric discharge letter template. This page covers only the report.

What the hospitalisation report is for

• Keeping an accurate account of the stay, useful if the patient is admitted again.
• Explaining treatment decisions, especially medication changes and the reasons for them.
• Giving the outpatient psychiatrist a complete picture, beyond the short summary of the liaison letter.
• Documenting the legal status of the stay, particularly for involuntary care.
• Answering a patient's access request with a clear, reviewed document.

The framework to follow

Medical confidentiality. The report is shared only between professionals involved in the patient's care, within the limits set by French law. Address it by name and send it through a secure channel.

Patient access. According to service-public.fr, hospitalisation reports are among the documents a patient can request. They must be provided within 8 days of the request, and not before a 48-hour reflection period. The deadline becomes 2 months for information more than 5 years old. Information given by third parties who are not involved in care cannot be disclosed. Write as if the patient will read the report.

Involuntary care. Service-public.fr also states that, where the patient's condition requires it, access to the record may take place in the presence of a doctor. If the patient refuses to name one, the departmental psychiatric care commission (CDSP) is asked to decide.

Retention. The report follows the retention rules for the medical record. See our page on patient record retention periods in France.

The outline, section by section

1. Identification

• Patient's name and date of birth.
• Unit, consultant in charge and author.
• Admission and discharge dates, length of stay.
• GP, outpatient psychiatrist, referring doctor.

2. Legal status of the stay

• Voluntary care (soins libres) or involuntary care, with the exact form (third-party request, emergency, imminent danger, decision of the prefect).
• Changes of status during the stay, with dates.
• Judicial review hearing, if any, and its outcome.

3. Reason for admission and context

• Who referred the patient and how (emergency department, clinic, transfer).
• What led to admission, as dated facts.
• Relevant social context (housing, family, work), without unnecessary detail about third parties.

4. History

• Psychiatric history, previous admissions, suicide attempts.
• Physical health history, allergies.
• Substance use.
• Usual medication before admission.

5. Assessment on admission

• Mental state examination on admission (see our mental status examination template).
• Physical examination and vital signs.
• Risk assessment as you documented it.

6. Course during the stay

• Clinical course, in stages rather than day by day.
• Notable events (absconding, seclusion or restraint, falls, physical illness).
• Work with family, social worker and community teams.
• Leave periods and how they went.

7. Investigations and specialist opinions

• Bloods, ECG, imaging, with significant results.
• Specialist opinions requested and their conclusions.
• Results still pending at discharge.

8. Medication

• Medication on admission, changes during the stay and the reason for each change.
• Tolerability and side effects observed.
• Full discharge medication, with dose and duration.
• Medication stopped and why.

9. Mental state at discharge

• Mental state examination at discharge, compared with admission.
• Type of discharge (routine, community treatment programme, transfer, discharge against medical advice).

10. Diagnosis

• Main and associated diagnoses, using the classification your hospital uses.
• Open hypotheses, stated as such.

11. Care plan and follow-up

• Booked appointments (community mental health centre, private psychiatrist, GP) with dates.
• Monitoring needed (blood tests, clinical review).
• What to do if symptoms return, as explained to the patient.
• Social support in progress.

12. Recipients and signature

• List of recipients, with the patient's agreement where required.
• Date, name and signature of the psychiatrist.

Filled-in example

Identification. Ms Claire D., 34. Adult inpatient unit. Admitted 2 March, discharged 23 March, 21 days. GP, Dr M. Outpatient psychiatrist, Dr S. (local community mental health centre).

Legal status. Voluntary care throughout the stay.

Reason and context. Referred by her GP for a depressive state worsening over six weeks, with sick leave, withdrawal at home and thoughts of death voiced to her GP. Lives alone, close sister available.

History. One depressive episode at 27, treated as an outpatient. No suicide attempt. No significant physical history. Occasional alcohol use, increasing over the past month. No medication on admission.

Assessment on admission. Neglected appearance, psychomotor slowing, poor speech output, low mood, anhedonia, early morning waking. Thoughts of death without a plan. No psychotic features. Good insight. Normal physical examination.

Course. First week spent mostly in her room. Antidepressant started, daily interviews. Sleep improved in the second week, then she joined unit activities. Two weekend leaves went well. Family meeting with her sister in the third week.

Investigations. Admission bloods, including TSH, normal. Normal ECG. No pending results.

Medication. Sertraline started at 50 mg daily, increased to 100 mg on day 10, well tolerated. Hydroxyzine at bedtime in the first week, stopped on day 8 as sleep improved.

Mental state at discharge. Improved mood, renewed interest, normal sleep. No further thoughts of death expressed. Part-time return to work discussed.

Diagnosis. Severe major depressive episode without psychotic features, in the context of recurrent depressive disorder.

Care plan. Appointment with Dr S. at the community centre on 30 March. GP appointment within two weeks. Continue sertraline 100 mg. Written crisis plan given to the patient.

Recipients. Dr M., Dr S. Liaison letter handed to the patient on 23 March and sent the same day.

Common mistakes

• Copying the liaison letter. If the report adds nothing, there is no reason to write it. Use it for reasoning and clinical course.
• Writing a day-by-day diary. Group events into stages. Readers want the turning points, not the nursing handover.
• Leaving out why medication changed. An unexplained change causes problems for the next prescriber.
• Omitting the legal status. Any period of involuntary care, however short, should appear with its dates.
• Quoting third parties carelessly. This information cannot be disclosed to the patient. Note where it came from and keep it to what is needed.
• Using value judgements. Describe observed behaviour rather than labels.
• Sending the report weeks after discharge. The later it arrives, the less use it is.

Save time with Delta

Delta is a clinical assistant for mental health and allied health professionals. During an interview, Delta transcribes what is said. After the interview, you can also dictate your observations and add written notes. Delta generates a report for each session and updates the patient record with a summary of care and the goals being tracked.

Delta also drafts letters, certificates and assessment reports adapted to your profession. For a hospitalisation report, you can dictate your notes following the outline above and get a first draft to review, complete and sign. The medical content remains your responsibility.

Data is hosted in France by an HDS-certified provider and AI processing takes place in France. The patient's name and identifying details are pseudonymised before the AI step. No audio file is kept, and data is never used to train a model. Read what is Delta or the Delta for psychiatrists page. The trial lasts 14 days with no credit card.

Frequently asked questions

Further reading

• Psychiatric discharge letter, structure and template.
• Psychiatric consultation report template.
• Mental status examination template.
• Psychiatrist's letter to the GP.
• Medical certificates in psychiatry.
• All our clinical document templates.
• Choosing an AI scribe as a psychiatrist.
• AI note-taking software compared.

Sources

• Decree no. 2016-995 of 20 July 2016 on liaison letters (Official Journal, reproduction, in French).
• HAS, quality indicator for the discharge liaison letter in psychiatry (in French).
• Service-public.fr, medical record and right of access (in French).
• AP-HP Henri-Mondor hospitals, medical documents in the patient record (in French).