Step epicrisis: an example of writing

In Russia, the concept of "epicrisis" was familiar in the 18th century. Epicrisis (from the Greek judgment, decision) is the opinion of the doctor: about the patient's health, the symptoms of the disease, its causes, diagnosis, the prescribed treatment and its results. Epicrisis is an obligatory document of business medical document circulation, it will be discussed in this article, where its types, conditions, composition and template will be considered.

Types of epicrisis

Opinion about the results of treatment is made when the patient has recovered or was discharged home to be cured, this epicrisis is called - discharge. It gives recommendations for further management of the patient. On the deceased patient a post-mortem epicrisis is composed, in which the cause of death is established. At certain intervals during the illness, usually once every 10-14 days, an additional epicrisis is formed, which was called a stage epicrisis.

The case history is conducted every day. On the third day of the illness, or if the patient is in the hospital for more than ten days or needs to be transferred to another doctor, a stage epicrisis is completed, which describes the patient's condition, the appointment of diagnostic treatment activities. The description may vary depending on the observation period in which it is being filled, the severity of the patient's illness, whether or not a diagnosis has been established.

Conditions

• If the diagnosis is not made, then in the epicrisis discuss the alleged diagnosis, diagnostic measures to confirm it.
• If the diagnosis is already established, then the stage of the disease, its prognosis, is described. The patient's complaints, laboratory and instrumental studies are described.
• In the future, epi-stage epilepsy describes the effectiveness of treatment, the doses of essential medicines, and the introduction of changes in therapy. The further tactics of treatment of the patient is determined.
• In case of severe illness, this document is drawn up more often if necessary.

Basic

In fact, the epicrisis summarizes the past stage of the disease and suggests further actions. Epicrisis is an opportunity to exchange information about a patient among medical institutions. Especially strictly follow the transfer of patients who have tuberculosis, oncology, mental illness, sexually transmitted diseases, cardiovascular diseases.

Example

Here is how the epicrisis is filled up - an example of writing.

20.03.11. Patient KD, 6 years old, at the place of residence was diagnosed with cirrhosis of the liver. He was sent to the Gastroenterology Department of the CSTO in Moscow, where the diagnosis was not confirmed, the portal vein, splenomegaly transformation was revealed. He was transferred to the Ministry of Agriculture No. 2 of the CSTO for additional examination and treatment. I entered the department on 05.03.11. State of moderate severity. Active, the liver is not palpable, spleen +6 cm. Urine is normal, en. Blood - Нв - 112, a lake. - 3,4, er. - 4.2, tr. - 70, the formula is normal. B \ x blood - all indicators are normal. UZGD: liver without pronounced structural changes, portal wall is dense, 108x60 mm, proliferation of connective tissue, pancreas: 16x15x18 mm, spleen is enlarged, 124x46 mm. Transformation of the portal vein. FGDS: in veins 3 and 3 of the esophagus 4 veins are defined: 3,3,5,6 mm of cyanotic color, strained, with multiple nodes, with transition to the arch of the stomach. Conclusion: grade IV. Gastroduodenitis. CT angiography: the superior mesenteric vein of 8 mm, the expansion of intrahepatic bile ducts to 5 and 10 mm. The diagnosis is confirmed.

16.03.11. The operation "Revision of the left branch of the portal vein was performed. Formation of spleno-renal anastomosis side-by-side. Bandaging the left gonadal vein. " The postoperative period was complicated by right-sided lower-left pneumonia. Antibacterial, infusion therapy was conducted. P / o control (3rd day): An. Urine - the norm, blood: HB - 118, watering can. - 7.6, er. - 4.4, tr. - 160, the formula is normal. B1 blood: protein - 62 g / l (the norm of 60), albumin 35 (the norm of 35 g / l), bilirubin 18.9 (the norm to 14 μmol / l), ALT - 63 (the norm to 45 IU / L), the remaining indicators are normal.

It is planned to remove the stitches on the 9-10th day after the operation, to make the EGF. With positive dynamics, prepare for discharge.

Epicrisis (example above) dispensary patient

This was an example of a stage epicrisis of a patient lying in a hospital. But there is still a stage epicrisis of the dispensary patient. This epicrisis is needed to monitor the effectiveness of the medical examination. The medical examination is necessary for strengthening the health of the population, increasing its efficiency. Healthy persons are subject to medical examination: pregnant women, children, students, employees of enterprises with harmful working conditions, people who are in close contact with the population (food workers, health workers, etc.) and those suffering from any diseases.

Stages of clinical examination

• The medical examination includes 3 stages.
• Carry out mandatory preventive examinations at enterprises or dispensary examinations (children, students) in order to assess the state of health, identify as early as possible any pathological processes.
• They constantly monitor people taken for dispensary registration. The duration of observation depends on the nature of the disease and ranges from one month to the end of the patient's life.
• Analysis of dispensary work. At the end of each year, the attending physician fills the stage epicrisis on the dispensary patient. It is made in two copies: one in the patient's outpatient card, and the other on a special form, which is given to the statistics office for centralized data processing, where an evaluation of its effectiveness is given.

Template

Here is the stage epicrisis: a template in which there should be such items as:

• Surname, name, patronymic, date of birth, how many full years, place of residence.
• The detailed proved diagnosis.
• Complaints of the patient.
• Anamnesis of the disease.
• The patient's initial condition.
• Laboratory and other studies.
• Consultations of specialists.
• What treatment was carried out. Whether the disease was prevented. If any operations were performed, the course of the operation is described, rather than anesthetized, the course of the development of the disease. How the patient's state of health has changed, the number of exacerbations has decreased or increased, how the number of days of incapacity for work has changed.
• Assessing the well-being (improvement, deterioration, without change) is carried out.

Epicrisis is given for signature to the head of the polyclinic department.

Conclusion

All children need to be examined by a doctor every year, and in 1 year, 3, 6, 7, 10, 14, 15, 16 and 17 years, an in-depth medical examination is carried out. At the age of 18, a stage epicrisis is composed when a person who has grown up is transferred from a children's polyclinic to an adult.

Thus, a stage epicrisis is compiled for every person, since his birth and is an obligatory document of any person, in medicine he is equated to a passport. It examines an anamnesis of the diseases with which the patient seeks medical help.

It is worth saying that in people epicrisis is called "card", it was with this name that everyone faced.