Landmark epicrisis: example of writing

In Russia with the concept of “medical” was familiar in the 18th century. Epicrisis (from the Greek. judgment, decision) – doctor's opinion: on the health of the patient, symptoms of the disease, its causes, diagnosis, medication and its results. A discharge summary is a mandatory document business medical document, it will be discussed in this article, which will consider types, terms, drafting and template.

Types of case history

Opinion about the results of treatment is made when the patient had recovered or were discharged home to convalesce, this is called medical report-discharge report. It provides recommendations for the further management of patients. On the deceased patient follows post-mortem epicrisis, which established a cause of death. At certain intervals during the disease, usually one every 10-14 days, compiled an additional medical report, which was called – a landmark epicrisis.

History is done every day. On the third day of the disease, or if the patient is in the hospital more than ten days, you have to translate it to another doctor, filled a staged case history, which describes the patient's condition, the purpose of diagnostic treatment. The description can vary depending on what observation period it is completed, from the severity of the disease the patient, is established or installed diagnosis.

Terms and Conditions

• If not diagnosed, the prognosis discuss the presumptive diagnosis, the diagnostic measures for confirmation.
• If the diagnosis is already installed, it describes the stage of the disease, its prognosis. Describes the patient's complaints, laboratory and instrumental examination.
• In a further step, the medical report describes the effectiveness of treatment, doses of key drugs, changes in therapy. Is defined further tactics of treatment.
• In severe disease this document is issued more often if needed.

Basic

In fact, the discharge summary summarizes the past stage of the disease and suggests further actions. Case history – the possibility of exchanging information about the patient among medical institutions. Especially strictly monitor the transfer of data of patients diagnosed with tuberculosis, cancer, mental illness, sexually transmitted diseases, cardiovascular diseases.

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Example

Here's how to complete the step case history-example of writing.

20.03.11. Patient K. D. A., 6 years old, by place of residence was diagnosed with cirrhosis of the liver. Was sent to the gastroenterology Department of the CSTO in Moscow, where the diagnosis was not confirmed, was revealed transformation of the portal vein, splenomegaly. Was transferred to the Ministry of agriculture No. 2 CSTO for further examination and treatment. Admitted to the Department 05.03.11. The state of moderate severity. Active, liver not palpable, spleen +6 see An. urine is normal, an. blood – NV-112, lake. – 3,4, er. – 4,2, Tr. – 70, the formula in norm. BKH blood - all parameters in norm. USGD the liver without obvious structural changes, the walls of the portal pool dense, 108х60 mm, the growth of connective tissue, the pancreas: 16х15х18 mm, the spleen is enlarged, 124х46 mm. Transformation of the portal vein. EGD: C3 and H3 of the esophagus are defined by 4 Vienna: 3,3,5,6 mm bluish in color, intense, with multiple nodes, with the transition to the body of the stomach. Conclusion: the esophagus, 4th degree. Gastro. CT angiography: superior mesenteric Vienna 8 mm, the expansion of the intrahepatic bile ducts up to 5 and 10 mm. the Diagnosis was confirmed.

16.03.11 G. the operation was carried out “Revision of the left branch of the portal vein. The formation spleno-renal anastomosis side-to-side. Ligation of the left gonadal vein”. P/o period was complicated by right lower lobe pneumonia. Conducted antibacterial, infusion therapy. P/o control (3rd p/o day): An. urine-normal, blood: HB-118, lake. – 7,6, er. – 4,4, Tr. – 160, formula normal. BKH blood: protein-62 g/l (norm: 60), albumin 35 (norm: 35 g/l), bilirubin of 18.9 (14 µmol/l) ALT – 63 (45 IU/l), other indicators are normal.

Is Planned for 9-10 days after the surgery to remove the stitches, to make the EGD. In case of positive dynamics to prepare the statement.

Case history (example above), patient follow-up

It was an example of the landmark epicrisis of the patient lying in the hospital. But there is also landmark medical dispensary of the patient. This medical report is needed for tracking the performance of the clinical examination. Clinical examination is necessary for strengthening of health of the population, improving its health. Clinical examination of the subject as healthy individuals: pregnant women, children, students, employees of enterprises with harmful working conditions, persons closely in contact with the population (food industry, health workers, etc.) and suffering from any disease.

Stages of examination

• Clinical Examination consists of 3 stages.
• Conduct mandatory preventive medical examinations at the enterprises or medical checkups (children, students) in order to assess health status, identify early any pathological processes.
• Constantly carry out surveillance of people, taken on a clinical account. The duration of observation depends on the nature of the disease and ranges from one month to the end of life of the patient.
• Analysisdispensary work. At the end of each year, the attending physician fills in a landmark epicrisis on the dispensary of the patient. It is made in two copies: one in the outpatient record of the patient, and the other – on a special form which is given to the office of statistics for centralized processing of medical examination, which provides an assessment of its effectiveness.

Template

That this should be a landmark epicrisis: the template, which must contain such items as:

• Last Name, first name, patronymic, date of birth, number of years of residence.
• Expanded-based diagnosis.
• The patient's Complaints.
• Medical History.
• The Initial condition of the patient.
• Laboratory and other studies.
• Expert Advice.
• What treatment was conducted. Whether prevention of the disease. If done any operation, then describes the course of the operation, than anesthetized, the development of the disease. How has the patient's state of health has decreased or increased number of exacerbations, how has the number of days of disability.
• Is it carried out well-being (improvement, worsening, no change).

The case history is given for signature to the head of the outpatient Department.

Conclusion

All children should be examined by a doctor each year, and 1 year, 3, 6, 7, 10, 14, 15, 16 and 17 years carried out in-depth medical examinations. In 18 years of the landmark epicrisis is made when translating a grown man from the pediatric clinic to the adult.

Thus, a staged case history is compiled for each person, beginning with his birth and is a binding document of any person, in medicine, it is equivalent to the passport. It examines the history of disease that the patient seeks medical help.

It is Worth saying that the people epicrisis is called "card" with this name encountered.