In Russia, the concept of "epicrisis" was familiar in the 18th century. An epicrisis (from the Greek. Judgment, decision) is the doctor's opinion: about the patient's he alth, the symptoms of the disease, its causes, diagnosis, the prescribed treatment and its results. The epicrisis is a mandatory document of business medical workflow, and it will be discussed in this article, where its types, conditions, compilation and template will be considered.
Types of Epicrisis
An opinion on the results of treatment is made when the patient has recovered or has been discharged home for further treatment, this epicrisis is called discharge. It provides recommendations for further management of the patient. A post-mortem epicrisis is drawn up for 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 compiled, which is called a staged epicrisis.
Medical history is taken every day. On the third day of illness, or ifthe patient is in the hospital for more than ten days or he needs to be transferred to another doctor, a stage epicrisis is filled in, which describes the patient's condition, the appointment of diagnostic therapeutic measures. The description may vary depending on the period of observation it is filled in, the severity of the patient's disease, whether or not a diagnosis has been established.
Conditions
- If the diagnosis is not made, then the epicrisis discusses the presumptive diagnosis, diagnostic measures to confirm it.
- If the diagnosis is already established, then the stage of the disease, its prognosis, is described. The patient's complaints, laboratory and instrumental studies are described.
- In the future, a milestone epicrisis describes the effectiveness of treatment, the doses of the main drugs, changes in therapy. Further treatment tactics for the patient are being determined.
- In case of severe illness, this document is issued more often if necessary.
Basic
In fact, the epicrisis summarizes the passed stage of the disease and suggests further actions. An epicrisis is an opportunity to exchange information about a patient among medical institutions. The transfer of data of patients with tuberculosis, oncology, mental illness, sexually transmitted diseases, cardiovascular diseases is especially strictly monitored.
Example
Here's how to fill in the stage epicrisis - an example of writing.
20.03.11. Patient KDA, 6 years old, was diagnosed with cirrhosis of the liver at the place of residence. Was sent togastroenterological department of the ODKB, Moscow, where the diagnosis was not confirmed, transformation of the portal vein, splenomegaly was revealed. He was transferred to the Ministry of Agriculture No. 2 of the CSTO for further examination and treatment. Entered the department on 03/05/11. Moderate condition. Active, liver 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. Ultrasound examination: the liver without pronounced structural changes, the walls of the portal pool are dense, 108x60 mm, the proliferation of connective tissue, the pancreas: 16x15x18 mm, the spleen is enlarged, 124x46 mm. Transformation of the portal vein. FGDS: 4 veins are determined in the s/3 and n/3 of the esophagus: 3, 3, 5, 6 mm, bluish in color, tense, with multiple nodes, with a transition to the fornix of the stomach. Conclusion: VRVP 4 degrees. Gastroduodenitis. CT angiography: superior mesenteric vein 8 mm, expansion of the intrahepatic bile ducts up to 5 and 10 mm. Diagnosis confirmed.
16.03.11 The operation “Revision of the left branch of the portal vein” was performed. Formation of a spleno-renal anastomosis side-to-side. Ligation of the left gonadal vein. The p/o period was complicated by right-sided lower lobe pneumonia. Conducted antibacterial, infusion therapy. P / o control (3rd p / o day): An. urine - norm, blood: Hb - 118, lake. - 7, 6, er. - 4, 4, tr. - 160, the formula is normal. B\x blood: protein - 62 g / l (norm from 60), albumin 35 (norm from 35 g / l), bilirubin 18, 9 (norm up to 14 μmol / l), ALT - 63 (norm up to 45 IU / l l), the rest of the indicators are normal.
It is planned to remove the stitches on the 9-10th day after the operation,do FGDS. With positive dynamics, prepare for discharge.
Epicrisis (example above) of a dispensary patient
This was an example of a milestone epicrisis of a patient in a hospital. But there is also a milestone epicrisis of a dispensary patient. This epicrisis is needed to track the effectiveness of the medical examination. Clinical examination is needed to improve the he alth of the population, increase its efficiency. Medical examinations are subject to both he althy persons: pregnant women, children, students, employees of enterprises with harmful working conditions, persons in close contact with the population (food workers, he alth workers, etc.), and those suffering from any diseases.
Stages of clinical examination
- Prophylactic examination includes 3 stages.
- Conduct mandatory preventive examinations at enterprises or dispensary examinations (children, students) in order to assess the state of he alth, to identify any pathological processes as early as possible.
- 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 out a milestone epicrisis for a dispensary patient. It is compiled in two copies: one in the patient's outpatient card, and the other on a special form, which is given to the statistics office for centralized processing of medical examination data, where its assessment is given.performance.
Template
This is how a milestone epicrisis should be: a template that must contain such items as:
- Last name, first name, patronymic, date of birth, how many full years, place of residence.
- Detailed substantiated diagnosis.
- Complaints of the patient.
- Case history.
- Initial state of the patient.
- Laboratory and other studies.
- Consultations of specialists.
- What kind of treatment was carried out. Has the disease been 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 state of he alth has changed, the number of exacerbations has decreased or increased, how the number of days of disability has changed.
- Assessment of well-being (improvement, deterioration, no change).
The 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 at 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 milestone epicrisis is compiled when a grown-up person is transferred from a children's clinic to an adult one.
Thus, a milestone epicrisis is compiled for each person, starting from his birth and is a mandatory document for any person, in medicine it is equivalent topassport. It is used to study the history of diseases with which the patient seeks medical help.
It is worth saying that the people call the epicrisis "card", it is with this name that everyone has come across.
