In Russia, the concept of “epicrisis” was familiar in the 18th century. Epicrisis (from the Greek judgment, decision) is the doctor’s opinion: about the patient’s health, symptoms of the disease, its causes, diagnosis, the prescribed treatment and its results. Epicrisis is a mandatory document of a business medical workflow, and it will be discussed in this article, which will discuss its types, conditions, compilation and template.
Types of Epicrisis
An opinion on the results of treatment is drawn up when the patient recovered or was discharged home to be treated, this epicrisis is called - discharge. It provides recommendations for further management of the patient. A posthumous epicrisis is made on the deceased patient, 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 is called - stage epicrisis.
A medical history is maintained every day. On the third day of illness, or if the patient is in the hospital for more than ten days or needs to be transferred to another doctor, a step-by-step epicrisis is filled out, which describes the patient's condition, the appointment of diagnostic treatment measures. The description may vary depending on what period of observation it is filled in, on the severity of the patient’s disease, whether the diagnosis is established or not.
Conditions
- If the diagnosis is not made, then in the epicrisis discuss the presumptive diagnosis, diagnostic measures to confirm it.
- If the diagnosis is already established, then the stage of the disease is described, its prognosis. The patient's complaints, laboratory and instrumental studies are described.
- In the future, a staged epicrisis describes the effectiveness of treatment, doses of essential drugs, and changes in therapy. Further treatment tactics for the patient are determined.
- In severe cases of the disease, this document is drawn up more often as necessary.
Main
In fact, the epicrisis summarizes the passed stage of the disease and suggests further actions. Epicrisis is an opportunity to exchange information about the patient among medical facilities. Particularly strictly monitored are the transmission of data from patients with tuberculosis, oncology, mental illness, sexually transmitted diseases, and cardiovascular diseases.
Example
Here's how a stage epicrisis is filled - an example of writing.
03/20/11. Patient K.D.A., 6 years old, was diagnosed with cirrhosis of the liver at the place of residence. He was sent to the gastroenterological department of the CSTO in Moscow, where the diagnosis was not confirmed, the portal vein transformation, splenomegaly were detected. He was transferred to the Ministry of Agriculture No. 2 of the CSTO for further examination and treatment. He entered the department 05.03.11. The state of moderate severity. Active, the liver is not palpable, spleen +6 cm. An. urine is normal, an. blood - HB - 112, 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, the walls of the portal basin are dense, 108x60 mm, proliferation of connective tissue, pancreas: 16x15x18 mm, spleen enlarged, 124x46 mm. Transformation of the portal vein. FGDS: in s \ 3 and n \ 3 of the esophagus, 4 veins are determined: 3.3.5.6 mm cyanotic color, strained, with multiple nodes, with a transition to the arch of the stomach. Conclusion: GRVP 4 degrees. Gastroduodenitis. CT angiography: superior mesenteric vein 8 mm, expansion of the intrahepatic bile ducts to 5 and 10 mm. The diagnosis is confirmed.
03/16/11 Operation “Revision of the left branch of the portal vein was performed. The formation of spleno-renal anastomosis side-by-side. Ligation of the left gonadal vein. " P / o period was complicated by right-sided inferior pneumonia. Antibacterial, infusion therapy was carried out. P / o control (3rd p / o day): An. urine - normal, blood: HB - 118, lake. - 7.6 er - 4.4, tr. - 160, the formula is normal. B / x blood: protein - 62 g / l (normal from 60), albumin 35 (normal from 35 g / l), bilirubin 18.9 (normal to 14 μmol / l), ALT - 63 (normal to 45 IU / k), other indicators are normal.
It is planned for 9-10 days after surgery to remove the sutures, to do FGDS. With positive dynamics, prepare for discharge.
Epicrisis (example above) of a dispensary patient
This was an example of a staged epicrisis of a patient lying in a hospital. But there is still a staged epicrisis of a dispensary patient. This epicrisis is needed to track the effectiveness of the clinical examination. Clinical examination is needed to strengthen the health of the population, increase its performance. Clinical examination is subject to both healthy persons: 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.), as well as those who suffer from any diseases.
Clinical examination stages
- Clinical examination includes 3 stages.
- Compulsory preventive examinations are carried out at enterprises or dispensary examinations (children, students) in order to assess the state of health, to identify any pathological processes as early as possible.
- They constantly monitor people taken to the dispensary. 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 in a staged epicrisis in the dispensary patient. It is compiled in two copies: one in the outpatient card of the patient, and the other on a special form, which is given to the statistics office for centralized processing of clinical examination data, where its performance is assessed.
Template
This should be a phased epicrisis: a template in which items such as:
- Surname, name, patronymic, date of birth, how many full years, place of residence.
- Detailed substantiated diagnosis.
- Complaints of the patient.
- Medical history.
- The initial condition of the patient.
- Laboratory and other studies.
- Consultations of specialists.
- What treatment was carried out. Whether the disease was prevented. If any operations were performed, then the course of the operation is described, what anesthetized, the course of the development of the disease. How the patient’s well-being changed, the number of exacerbations decreased or increased, how the number of days of disability changed.
- An assessment of well-being (improvement, deterioration, no change).
Epicrisis is given for signature to the head of the outpatient 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 staged epicrisis is compiled when a grown-up person is transferred from a children's clinic to an adult.
Thus, a staged epicrisis is compiled for each person, starting from his birth and is an obligatory document of any person, in medicine it is equated to a passport. It examines the history of diseases with which the patient seeks medical help.
It is worth saying that in the people an epicrisis is called a "card", it is with this name that everyone has encountered.