An epicrisis is an extract from a medical record. It displays all the dynamics of the patient's condition and treatment during the period of stay in a medical institution. Epicrisis can be staged, discharged, transferable, postmortem and postmortem.
Instructions
Step 1
When the patient is in the hospital for a long time, fill out a milestone epicrisis every 10-14 days. Indicate in it the date and time of admission of the patient, his complaints. Describe the details of the medical history, i.e. how and when the patient fell ill, how his condition changed from the onset of the disease to admission to the hospital. Next, present the data obtained during the examination and laboratory and instrumental examination. Include only those data that support your diagnosis. Write down the treatment the patient is receiving. Finish the milestone epicrisis with a description of the future treatment for the patient.
Step 2
When the patient is discharged from the hospital, fill out the discharge summary. Start it by specifying the date of admission and the date of discharge. Then, as in the staged epicrisis, indicate the complaints upon admission, medical history, examination data and treatment. If the patient was operated on, indicate the name of the operation. End the discharge summary with the words that the patient's condition has improved as a result of the treatment. Write down the recommendations you gave the patient at discharge (medication, observation by the GP, etc.).
Step 3
When transferring a patient from one department to another within the same medical institution or from one hospital to another, issue a transfer epicrisis. Write it in the same way as you write it out. End the epicrisis with an explanation of the reason for the transfer.
Step 4
If the patient dies during treatment, issue a postmortem epicrisis. Reflect in it complaints upon admission, medical history, data from examinations and laboratory and instrumental studies, the dynamics of deterioration. Next, describe the cause and circumstances of the death. Complete the postmortem epicrisis with a detailed clinical postmortem diagnosis.
Step 5
The pathological epicrisis is filled in after opening by a pathologist. It describes the mechanism of the death of a given patient (thanatogenesis). The data from intravital studies and the data obtained during the autopsy are compared. The postmortem epicrisis ends with a detailed postmortem diagnosis.
