The number of different medical documents currently used by doctors is very large. At the same time, one of the central places is occupied by the medical card of the inpatient. This document has a fixed format, however, depending on the specific center and its focus, it may differ in minor details.
What sections are there in the medical record?
On its front side there is a place to indicate the last name, first name and patronymic of the patient, the name of the department and ward number, the final diagnosis, as well as the 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 referred the patient for hospitalization.
Diagnosis
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 referring organization is indicated. It should be noted that it is not always true. This is followed by a place for clinical diagnosis. This part is filled in by a doctor from the specialized department in which the patient is being treated. This section must be completed within 3 days (this is how much time is given to the attending physician to determine the cause of the disease). After it, there is a special form, which indicates the final diagnosis, that is, the one with which the patient is discharged. It may have some differences from clinical. Here, not only the name of the pathology itself is entered, but also its code, which is determined according to the ICD-10 classification.
Dynamic surveillance
This does not end the medical record of an inpatient. The sample of any medical record includes information about the condition in which the patient was admitted. There are two dedicated sections for this. The medical record of an inpatient contains a place for detailed examination data by a doctor in the admissions department. The second of these is the "Initial 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 an inpatient includes a section requiredso that the doctor can enter information about the patient's periodic examinations into the history. This part is intended to enable the doctor to observe the clinical course of a particular pathology. Due to this column, continuity between medical workers is facilitated. For example, it happens that the patient is first treated by one doctor, and then he moves to another specialist. Without information reflecting what happened to the patient before, it will be problematic for a new doctor to immediately navigate the treatment plan.
In addition, the inpatient record form includes a section required for entry by consulting physicians.
Diagnostic section
It includes any medical record of an inpatient. A form with the received analyzes, as well as the results of instrumental studies, will help the doctor to quickly navigate 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 may be supplemented over time by the results of new research.
Epicrisis
The registration of a medical record of an inpatient continues with writing an epicrisis. This section is a kind of brief excerpt from all other parts of the case history. Here the doctor indicates all the most important information about the initial condition of the patient, the diagnosis, the resultslaboratory tests and instrumental studies, as well as the volume and effectiveness of the treatment. Usually, at the epicrisis, the filling out of the medical record of the inpatient ends.
Statement
After a person has completed a full course of treatment in a hospital, he is discharged from the department. At the same time, the now former patient is given a document certifying his stay in the hospital. In many ways, it resembles an epicrisis. This extract is necessary for a person for the reason that it confirms the fact that a doctor has established a particular diagnosis. It should be taken to the clinic at the place of residence. This is necessary so that the doctor who treats a 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 the MREK.
Ultimately, the discharge is necessary for the patient himself. The matter is that its final points are "Recommendations". There, the doctor indicates everything that the patient needs to do so that the recovery process goes as quickly as possible and without relapses. 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 an acute pathology.
Why is a medical history needed?
First of all, it is a legala document that can be one of the key in the process of resolving certain disputes. If the patient has complaints about his doctor or, conversely, the medical staff has complaints about a person undergoing inpatient treatment in their institution, then all attention is again drawn to the medical history.
Another important task of any inpatient medical record is communication between doctors from different institutions. The fact is that the extract is issued on the basis of the medical history. There are both diagnoses established in the hospital, as well as all the results of laboratory and instrumental studies performed in the hospital. In the event that a person takes his statement to the clinic, his doctor will have more complete information about him.
Currently, for the closest possible communication between he althcare institutions, new approaches are being developed to transfer discharges from the hospital 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.
