A discharge epicrisis, a medical history

A discharge epicrisis is a special form of recording the opinion of doctors about the patient's diagnosis, his health status, the course of the disease and the results of the prescribed treatment. The general content of most medical reports has a standard form, and only the final part of them may differ depending on the form of the document. Epicrisis is a mandatory section of medical records. Based on the characteristics of the course of the disease and the result of treatment, it can include the assumptions of the attending physician about the future prognosis of the patient, medical and labor regulations and recommendations for further monitoring of the disease.

The epicrisis introduced into the history of the disease can be of several types: stage, discharge, transfer and posthumous epicrisis. In the case of a clinical-anatomical study of the deceased, an additional pathoanatomical epicrisis is prescribed. The need for a medical report can arise at different stages of the patient's treatment. The epicrisis is recorded in the patient's medical record in order to assess the medical examination readings up to two times a year, and also, if necessary, to justify continuation of the treatment when the patient is hospitalized and referred to the WCC.

The history of the development of the child at the age of 1, 3, 7 and 18 years is also made epicrisis. Disease history Of the inpatient patient is reflected in the medical chart on the basis of his stay in the hospital for every 10-14 days and is called a terminal epicrisis. During the discharge of the patient from the hospital an epicrisis is written out. When transferring a patient to another medical institution, a transferable epicrisis is issued. A posthumous is the final document, indicating the onset of the patient's death, he is subsequently supplemented by a pathoanatomical conclusion.

The discharge epicrisis, like all other types of conclusions, must contain the passport part, the information of the expanded clinical diagnosis, the important information for the anamnesis about the stages of the disease, the indications of medical examinations and the recommendations of specialists. When establishing a new diagnosis, the epicrisis necessarily includes data confirming its reliability. The effectiveness of the prescribed treatment is assessed and characterized in stages. When performing a surgical operation in the discharge epicrisis, it is necessary to give instructions on the type of anesthesia, the course of the operation, its nature and the results of its conduct. If it is necessary to further transfer the operated patient to another medical unit, these data are entered in the translation epicrisis. And in the event of an unsuccessful operation that caused a fatal outcome of a stationary patient, all these data are included in the evidence of the posthumous epicrisis.

A discharge epicrisis should contain an outcome of the disease in one of the following variants of formulation: complete recovery of the patient, partial recovery, patient's condition without changes, transition of the current disease from acute to chronic and general deterioration of the patient's condition. With partial recovery, a further prognosis of the course of the disease is made, recommendations for further treatment are prescribed, and the patient's ability to work is assessed in the following categories: limited ability to work, transfer to easier work, disability.