The number of various medical documents currently used by doctors is very large. In this case, one of the central places is occupied by the medical record of an inpatient. This document has an established format, however, depending on the specific center and its focus, it may differ in unimportant details.
What sections are on the medical record?
On its front side there is a place to indicate the patient's last name, first name and patronymic name, department name and ward number, final diagnosis, as well as dates of admission and discharge.
The title page is followed by the administrative part. All possible details of the patient are indicated there. We are talking about his last name, first name and patronymic, place of registration, passport number, form of treatment (budget or paid), the organization that sent the patient to hospitalization.
Diagnoses
After general information about the patient, the medical record of the inpatient continues with a sheet indicating the diagnosis. After the patient enters the admission department, it is in this section that the diagnosis of the sending organization is indicated. It should be noted that it is not always true. The following is a place for a clinical diagnosis. This part is filled in by the doctor from the specialized department in which the patient is being treated. This section should be drawn up within 3 days (this is how much time is allocated to the attending physician to determine the cause of the disease). After it there is a special form where the final diagnosis is already indicated, that is, the one with which the patient is discharged. It may have some differences from the clinical. Here, not only the name of the pathology is entered, but also its code, determined according to the classification of ICD-10.
Dynamic observation
This does not end the medical record of the inpatient. A sample of any medical history includes information about the condition of the patient. There are two specially designated sections for this. The medical record of the inpatient contains a place for data of a detailed examination by the doctor of the admission department. The second of them is the "Primary examination by the attending physician." Moreover, the latter can be carried out independently, together with the head of the department or together with doctors of a different profile.
Further, the medical record of the inpatient includes the section necessary for the doctor to be able to record information on the patient’s periodic examinations. This part is intended so that the doctor has the opportunity to observe the clinical course of a particular pathology. Due to this column, the continuity between medical workers is facilitated. For example, it happens that the patient is first led by one doctor, and then he moves to another specialist. Without information showing what happened to the patient before, it will be problematic for the new doctor to immediately orient in the treatment plan.
In addition, the inpatient medical record form includes a section necessary for medical doctors to make notes.
Diagnostic Section
It includes any medical record of an inpatient. A form with the obtained analyzes, as well as the results of instrumental studies, will help the doctor to quickly orientate and establish the only correct diagnosis.
On these pages, the doctor can compare all the necessary indicators, on the basis of which a certain pathology will be suspected. This section over time may be supplemented by the results of new studies.
Epicrisis
Registration of a medical record of a hospital patient continues by writing an epicrisis. This section is a kind of brief excerpt from all other parts of the medical history. Here, the doctor indicates all the most important information about the initial condition of the patient, the diagnosis, the results of laboratory tests and instrumental studies, as well as the volume and effectiveness of the treatment. Usually at the epicrisis, the completion of the medical record of a hospital patient ends.
Statement
After a person has undergone a full course of treatment in a hospital, he is discharged from the department. At the same time, a document certifying his stay in the hospital is now issued to the hands of the former patient. It is much like an epicrisis. This extract is necessary for a person for the reason that it confirms the fact that the doctor made this or that diagnosis. She should be taken to the clinic at the place of residence. This is necessary so that the doctor who is treating the person on an outpatient basis has complete information about the pathology that is present in his patient. In addition, the original extracts from the hospital may be needed if a person needs to register a disability group through MREC.
Ultimately, the discharge is necessary for the patient himself. The fact is that its final points are “Recommendations”. There, the doctor indicates everything that the patient needs to do so that the healing process goes as quickly as possible and without relapse. Compliance with the recommendations is the most important condition for preventing the progression of an existing chronic disease, as well as reducing the likelihood of acute pathology.
What is a medical history for?
First of all, it is a legal document, which may be one of the key in the process of resolving certain disputes. If the patient has a complaint to his doctor or, conversely, the medical staff has complaints about a person undergoing inpatient treatment at their institution, then all attention is again drawn to the medical history.
Another most important task of any hospital patient record is communication between doctors from different institutions. The fact is that an extract is issued on the basis of the medical history. There are both diagnoses made in the hospital and all the results of laboratory and instrumental studies performed in the hospital. In the event that a person takes his discharge to the clinic, his treating doctor will have more complete information about him.
Currently, for the closest possible communication between healthcare institutions, new approaches are being developed for transferring hospital discharge to the outpatient network. First of all, we are talking about computer technologies that allow you to transfer a large amount of information via the Internet. This method is quite convenient, but requires the development of serious software to facilitate the search for the clinic to which the person is assigned, as well as the full protection of the transmitted data from unauthorized access by third parties.