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

VA Office of Inspector General · Report 26-01435-02 · October 8, 2026 · Office of Healthcare Inspections

What the OIG found

The OIG combined what it had found across 10 inspections of VA inpatient mental health care carried out between January 2024 and August 2025, and the same failures kept recurring from system to system. Discharge instructions were frequently written in technical terminology and medical abbreviations that can leave a veteran unsure where to go, what a medication is for, or what happens next — raising the risk of missed appointments, medication errors, and broken continuity of care. The inspectors also found widespread failure to document the required risk-benefit discussions before starting veterans on new medications, which means there is little assurance patients were given the information needed to make informed decisions. Individual facilities made local fixes — revised templates, clearer clinic names, staff education — but because the deficiencies were so consistent, the OIG concluded this is a system-wide problem needing national oversight, and made three recommendations to the Under Secretary for Health. VHA responded with an action plan.

Who it concerns

Veterans Health Administration (VHA) inpatient mental health services — findings rolled up from 10 inspected healthcare systems

Why it matters to a family

Discharge instructions are the piece of paper a family actually lives by after a hospitalization. When that paper is written in abbreviations, leaves out where the next appointment is, or never explains what a new drug is for, the care plan falls apart at home — and it is the family, not the hospital, who picks up the pieces.

The official report

The OIG’s report page · Full report (PDF)

Summary ours; the report is the OIG’s. Read it at vaoig.gov →