A discharge summary is a special form of recording the opinion of doctors about the patient's diagnosis, his state of he alth, 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 their final part may differ depending on the form of the document. The epicrisis is a mandatory section of medical documentation. 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 monitoring of the disease.
An epicrisis entered into the medical history can be of several types: stage, discharge, transfer and posthumous epicrisis. In the case of a clinical and anatomical examination of the deceased, an additional pathological epicrisis is written out. The need to draw up a medical report may arise at different stages of the patient's treatment. An epicrisis is recorded in the patient's medical record in order to assess the indications for medical examinationup to two times a year, as well as, if necessary, to justify the continuation of treatment during hospitalization of the patient and referral to VKK.
An epicrisis is also compiled about the history of the development of a child at the age of 1, 3, 7 and 18. The medical history of an inpatient 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 milestone epicrisis. At the time of discharge of the patient from the hospital, a discharge summary is compiled. When transferring a patient to another medical institution, a transfer epicrisis is issued. And the postmortem is the final document testifying to the death of the patient, subsequently it is supplemented by a pathoanatomical conclusion.
A discharge summary, like all other types of conclusions, should contain a passport part, details of a detailed clinical diagnosis, information about the stages of the disease that is important for the anamnesis, indications of medical examinations and recommendations from specialists. 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 performing a surgical operation, the discharge epicrisis must include instructions on the type of anesthesia, the course of the operation, its nature and the results of its implementation. If it is necessary to further transfer the operated patient to another medical unit, these data are entered in the transfer epicrisis. And in the event of an unsuccessful operation that resulted in the death of an inpatient, all thesethe data is entered into the post-mortem epicrisis certificates.
The discharge epicrisis should contain a conclusion of the outcome of the disease in one of the following wordings: complete recovery of the patient, partial recovery, the patient's condition unchanged, the transition of the current disease from its acute form to chronic and general deterioration 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 ability to work is assessed in the following categories: limited ability to work, transfer to easier work, disability.
