Prescription epicrisis is a special form of recording the opinions of doctors about the patient’s diagnosis, his state of health, 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 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 may include the assumptions of the attending physician about the further prognosis of the patient, medical and labor prescriptions and recommendations for further observation of the disease.
Epicrisis recorded in the history of the disease can be of several types: stage, discharge, transfer and post-mortem epicrisis. In the case of a clinical anatomical study of the deceased, an additional pathological epicrisis is prescribed. The need for a medical report may arise at different stages of treatment of the patient. The epicrisis is recorded on the patient’s medical records with the aim of evaluating the clinical examination indications up to two times a year, as well as, if necessary, substantiating the continuation of treatment during hospitalization of the patient and his referral to the ICC.
An epicrisis is also made about the history of the development of a child aged 1, 3, 7, and 18 years. Medical history a hospital patient is reflected in the medical record based on the results of his stay in the hospital for every 10-14 days and is called a staged epicrisis. During the discharge of the patient from the hospital, an epicrisis is drawn up. When a patient is transferred to another medical institution, a translated epicrisis is prescribed. And the posthumous is the final document indicating the death of the patient, subsequently it is supplemented by a pathological conclusion.
The written out epicrisis, like all other types of conclusions, should contain the passport part, information about the expanded clinical diagnosis, important information about the stages of the disease, medical testimonies and recommendations of specialists for the medical history. When a new diagnosis is established, data confirming its reliability must be entered into the epicrisis. The effectiveness of the prescribed treatment is evaluated and characterized in stages. When carrying out a surgical operation, an instruction on the type of anesthesia, the course of the operation, its nature and the results of its conduct must be made in the discharge epicrisis. If it is necessary to further transfer the operated patient to another medical unit, these data are entered into the translated epicrisis. And in the event of an unsuccessful operation that resulted in a fatal outcome of a hospital patient, all these data are entered into the evidence of a post-mortem epicrisis.
The written out epicrisis should contain a conclusion of the outcome of the disease in one of the following formulations: the patient’s full recovery, his partial recovery, the patient’s condition without changes, the transition of the current disease from its acute form to a chronic and general worsening 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 working capacity is assessed in the following categories: limited working capacity, transfer to easier work, disability.