Review of Roll-up Findings on Discharge Instructions and Risk-Benefit Discussions from Inspections of VA Inpatient Mental Health Care

The VA Office of Inspector General (OIG) synthesized findings from 10 inspections of Veterans Health Administration’s (VHA’s) inpatient mental health services conducted between January 2024 and August 2025. This review identified recurring deficiencies involving a lack of clarity, completeness, and quality of discharge instructions, as well as the lack of documentation of risk-benefit discussions for newly prescribed medications. 

While facilities generally provided discharge instructions and arranged follow-up care, the OIG found recurring shortcomings in the use of patient-friendly language and documentation of medication purposes. Discharge instructions frequently relied on technical terminology and medical abbreviations that could hinder veterans’ understanding of their care plans and increase the risk of missed appointments, medication errors, and disruptions in continuity of care.

The OIG also found widespread noncompliance with requirements for documenting risk benefit discussions prior to initiating new medications. Without documentation of these discussions, there is limited assurance that veterans have sufficient information needed to make informed decisions about their treatment options. 

These recurring deficiencies, observed across VHA healthcare systems, indicate broader system wide challenges rather than isolated facility issues. Although facilities implemented local corrective actions—such as revising templates, improving clinic naming conventions, and educating providers—the consistency of deficiencies suggests a need for standardized national oversight and accountability.

The OIG made three recommendations to the Under Secretary for Health: two to improve discharge instruction content and one to ensure risk-benefit discussions are documented prior to newly prescribed medications being administered. In response to the OIG’s recommendations, VHA provided an action plan to ensure patient friendly names are used for discharge instructions, providers accurately document newly prescribed medications, and veterans receive meaningful risk-benefit discussions prior to the initiation of newly prescribed medications.