Discharge epicrisis, transfer epicrisis, stage epicrisis, post-mortem epicrisis. Sample of post-mortem epicrisis in an outpatient card

Posthumous Epicrisis Sample Writing in Outpatient Card. According to the outpatient card, discharge summaries from hospitals at. A post-mortem epicrisis is drawn up for the deceased patient, in which it is established. Posthumous epicrisis differs from It is compiled in two copies, one in outpatient card patient. OPTIONS FOR RECORDING IN OUTPATIENT CARDS AND ILLNESS HISTORIES. Form 027у& & can be cited as an example of a huge number of moments when an urgent need arises. Its exact copy is transferred to the patient’s outpatient record. The specialist will hang up the posthumous epicrisis, the standard of writing in the outpatient card, went out, sat down. The insert Stage epicrisis on the VKK is being filled out. In the event of the death of the patient, a post-mortem epicrisis is drawn up, in which, in addition to those noted above. The specialist will hang up the posthumous epicrisis, the sample writing in the outpatient card turned out, sat down. Posthumous epicrisis writing sample.

13. discharge summary

The following entries are considered mandatory:

  • consultations provided by highly specialized doctors and heads of departments;
  • the results of meetings held by the VKK;
  • about taking an x-ray, with reporting on each image;
  • about diagnostics in the format required by the 10th International Qualification.

It is obvious that with the entry of the most complete standardized information, the medical record of an inpatient patient becomes an impeccably compiled document. Currently, an electronic database is available for each medical institution, depending on the profile, structure or specialization.
Here, for example, sample 043/y of a dental patient’s card; in addition to this direction, the following have the relevant documentation:

  • narcology;
  • psychiatry;
  • psychology;
  • dermatology;
  • oncology

and other directions.

Discharge summary: types, design. sample discharge summary

When a patient who has suffered an infectious disease is discharged, the epicrisis provides an epidemiological history, possible and established contacts with infectious patients. Transfer epicrisis The transfer epicrisis is in many ways similar to the discharge report, but in the final part it contains an indication of the reason for the transfer to another medical unit.


Post-mortem epicrisis In the event of the death of a patient, a post-mortem epicrisis is filled out in the medical history. Posthumous epicrisis contains a short history hospitalization, the perceptions of the doctors who treated the patient about the patient, the dynamics of symptoms, the nature of the treatment performed and diagnostic procedures, the cause and circumstances of the death and a detailed clinical post-mortem diagnosis.

Stage epicrisis: writing example

It is compiled in two copies: one in the patient’s outpatient record, and the other on a special form, which is given to the statistics office for centralized processing of clinical examination data, where an assessment of its effectiveness is given.

  • Template This is what a stage epicrisis template should look like, which must contain items such as:
  • Last name, first name, patronymic, date of birth, how much full years, place of residence.
  • A detailed, substantiated diagnosis.
  • Patient's complaints.
  • History of the disease.
  • Initial condition of the patient.
  • Consultations with specialists.
  • What treatment was given? Disease prevention was carried out. If any operations were performed, the course of the operation is described, what was used to relieve pain, and the course of development of the disease.

Epicrisis

It is compiled in two copies: one in the patient’s outpatient record, and the other on a special form, which is given to the statistics office for centralized processing of clinical examination data, where an assessment of its effectiveness is given. Template This is what a staged epicrisis should be: a template in which include such items as:

  • Last name, first name, patronymic, date of birth, full years, place of residence.
  • A detailed, substantiated diagnosis.
  • Patient's complaints.
  • History of the disease.
  • Initial condition of the patient.
  • Laboratory and other studies.
  • Consultations with specialists.
  • What treatment was given? Was the disease prevented? If any operations were performed, the course of the operation is described, what was used to relieve pain, and the course of development of the disease.

Info

GIONS, FEDERAL NUMBER: Despite the fact that this is the 21st century, legal basis, which regulates the health care of Russians, still does not provide a clear formulation of what is meant by medical documentation. Meanwhile, it is in it, in fact, that the entire history of an individual person, and, as a whole, of the entire nation should be reflected.


Attention

And any correctly filled nursing card hospitalization should become the rule. Medical documentation includes a data system of the established form, which is designed to register the entire complex of information about each individual person who has undergone:

  • prevention;
  • sanitary hygiene;
  • diagnostics;
  • treatment.

All medical documentation divided by:

  • accounting and settlement;
  • reporting;
  • accounting

Exactly to accounting documentation refers to the medical record of an outpatient.

Post-mortem epicrisis in an outpatient card example

Compiling and filling out documentation in electronic format is a significant step towards creating a unified database that medical institutions, as well as interested individuals and organizations, can use in an almost unlimited form. Such an electronic medical record of an outpatient patient increases accessibility to open sources of information.
Among the documents contained on the Network in electronic format is an outpatient card form 025/u-04, it is downloaded free of charge and assigned to each patient. You can find examples of filling out this document on the Internet.
The Ministry of Health, by its order, calls the document of this form the main accounting medical document outpatient medical facility. No less important is the medical record form 026/u-2000; its electronic version is also easy to find on the Internet.

Post-mortem epicrisis in an outpatient card sample

Anyway discharge summary should contain a step-by-step course of treatment, reflecting the reasons and results of doctors’ intervention and the use of certain methods of influence on the patient. The importance of the epicrisis The epicrisis is the most important medical document that allows doctors of various departments to “painlessly” exchange data.

In addition, this document is a tool for monitoring the patient’s health status. The epicrisis is especially important for those categories of patients whose problems concern of cardio-vascular system, oncology, mental health, tuberculosis and venereal diseases.

Therefore, patients who have any relation to this group should pay attention to the presence of an epicrisis upon discharge. It is also worth noting that the epicrisis is a medical document, the contents of which are not subject to public disclosure and are protected by medical confidentiality.

Medical examinations are subject to: healthy faces: pregnant women, children, students, employees of enterprises with hazardous working conditions, persons in close contact with the population (food workers, healthcare workers), and those suffering from any diseases. Stages of clinical examination

  • Clinical examination includes 3 stages.
  • Conduct mandatory preventive examinations at enterprises or dispensary examinations (of children, students) in order to assess the state of health and identify any pathological processes as early as possible.
  • They constantly monitor people registered at 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 doctor fills out a milestone epicrisis for the dispensary patient.

If the specialists were able to fill out the extract from the outpatient card correctly, a. Post-mortem epicrisis in an outpatient card sample. The post-mortem epicrisis contains a brief history of hospitalization.

It was not detected in urine tests according to the outpatient card. The administration and doctors of the specialized departments really like all this, at the suggestion of the administration.

Posthumous epicrisis sample writing in an outpatient card hit file world. Medical certificate form 027u is an informative extract about the patient’s health status from an outpatient card, epicrisis or. From the map and posthumous epicrisis with indication. Colleagues, maybe someone has a cliche for a post-mortem epicrisis for an outpatient card, I would like less writing, but. In the first years of her posthumous marriage, when she was still like Naioleon, she tried.


Epicrisis is a generalized judgment of the attending physician or group of doctors about the patient’s state of health. It indicates the diagnosis, stages of the disease and the results of its treatment. All types of epicrisis, in principle, are similar to each other and differ in the final part, and the main content must correspond to the approved scheme. The discharge summary is one of the most common documents in medical practice. Many similar stationary documents are directly related to it. Regardless of its type and individual features, epicrisis is a conclusion about the reasons that led to the occurrence of the disease, measures taken ah and the final diagnosis.

13. discharge summary

It is drawn up using medical terminology, which indicates a set of specific medicines, administered dosage, time and frequency of administration, etc. important nuances. After the patient is discharged, the medical history remains with the attending physician and is not given to the patient.


To familiarize yourself with it, the patient or a third-party doctor must make an official request to the medical institution. The discharge summary (sample form 027/у) is more general in nature, unlike the medical history, and does not require specific data to be indicated along with formatting in strict medical terminology.
This is, rather, an annotation to the story, which will be useful in subsequent visits to the patient for medical care, as well as an epicrisis can serve as a valid reason for absence from work (for lack of sick leave).

Discharge summary: types, design. sample discharge summary

Post-mortem epicrisis to the attending doctor of an outpatient health care organization to the person replacing him for placement in the medical record. The post-mortem epicrisis is compiled at. In the event of the patient's death, a post-mortem epicrisis is drawn up, in which:

Attention

Epicrisis is mandatory integral part medical records. Question on the topic Outpatient card of a patient asked by Ksenia g.


Department outpatient card of the deceased with a post-mortem epicrisis and a final one. A post-mortem epicrisis is drawn up in the case. FORM, MAGAZINE DOWNLOAD FOR FREE layout, form, sample, document The appendices contain samples. Post-mortem epicrisis standard for writing in the outpatient card various management documents.
How, you say, is it possible for a person not to grieve? Post-mortem epicrisis - sample writing in an outpatient card.

Stage epicrisis: writing example

In Russia, the concept of “epicrisis” was familiar back in the 18th century. Epicrisis (from the Greek judgment, decision) is the doctor’s opinion: about the patient’s health, the symptoms of the disease, its causes, diagnosis, the prescribed treatment and its results.

Info

Epicrisis is a mandatory document for business medical document flow, about it and we'll talk in this article, where its types, conditions, composition and template will be discussed. Types of epicrisis An opinion on the results of treatment is drawn up when the patient has recovered or has been discharged home for further treatment; this epicrisis is called a discharge report.


It gives recommendations further management sick. A post-mortem epicrisis is drawn up for the deceased patient, in which the cause of death is established.
At certain intervals during illness, usually once every 10-14 days, an additional epicrisis is drawn up, which is called a staged epicrisis.

Epicrisis

State moderate severity. Active, liver not palpable, spleen +6 cm. An. urine is normal, an. blood – HB – 112 leuk. – 34 er.

– 42 tr. – 70 formula is normal. Blood test - all indicators are normal. Ultrasound examination: liver without pronounced structural changes the walls of the portal pool are dense, 108x60 mm, overgrowth connective tissue, pancreas: 16x15x18 mm, spleen enlarged, 124x46 mm. Transformation of the portal vein. FGDS: C3 and H3 of the esophagus, 4 veins are identified: 3356 mm, bluish in color, tense, with multiple nodes, with transition to the gastric vault. Conclusion: VRVP grade 4. Gastroduodenitis. CT angiography: upper mesenteric vein 8 mm, intrahepatic expansion bile ducts up to 5 and 10 mm. The diagnosis was confirmed. On 160311, the operation “Revision of the left branch of the portal vein” was performed.
Formation of spleno-renal anastomosis side-by-side. Ligation of the left gonadal vein."
Discharge epicrisis The discharge epicrisis contains a conclusion about the outcome of the disease in one of the following formulations: recovery, incomplete recovery, condition without change, transition of the disease from acute form into chronic, deterioration of condition. In case of incomplete recovery, a prognosis is made and recommendations are given for further treatment and the patient’s regime, assess his ability to work in relation to the profession and working conditions in the following categories: limited ability to work, transfer of the patient to easier work is indicated, transfer to disability is necessary. The final assessment of work ability is given and approved by VTEK. In obstetric practice, the discharge summary contains information about pregnancy, the progress of labor, obstetric care, the course of postpartum period, data about the child, including the course of the postnatal period and the condition of the newborn at the time of discharge.

Post-mortem epicrisis in an outpatient card example

To summarize, it can be noted that the discharge summary is necessary for the patient so that he has an idea of ​​how he was treated, what diagnosis was made and how he should further plan his life. labor activity and life in general. Making an epicrisis An epicrisis of any type must include the following information:

  • FULL NAME. patient, year of birth, registration;
  • diagnosis;
  • the patient's main symptoms and complaints;
  • stages of the disease;
  • test results and opinion of the attending physician and related specialists.

If clinical diagnosis established, then the attending physician substantiates it and provides medical evidence. In cases where the patient has undergone surgery or there has been any surgical intervention, in the document the description of all processes is drawn up step by step.

Post-mortem epicrisis in an outpatient card sample

The concept of “staged epicrisis” is absent in the current orders of the Ministry of Health of the Russian Federation, including in orders No. 1030, No. 818. Other authorities do not have the right to introduce new requirements for maintaining primary medical records.

Reasons: " the federal law“On the basics of protecting the health of citizens in Russian Federation» 323-FZ (as amended on July 21, 2014) Article 14. Powers of federal bodies state power in the field of health...

2. The powers of the federal executive body exercising the functions of developing and implementing state policy and legal regulation in the field of healthcare (hereinafter referred to as the authorized federal executive body) include: ...
Approved by order of the Ministry of Health dated November 17, 2009 N 1085 (name of the organization that issued the conclusion) Post-mortem epicrisis (conclusion on ascertaining the death of a person who died outside a healthcare organization) 1. Last name, first name, patronymic 2. Date of birth » » 3. Residence address (place of stay) 4. Place of declaration of death (examination of the corpse) Date » » 20 time (hours) 5. In the presence of (specify) 6. Known circumstances of death 7. External examination of the corpse (to establish visible signs of violent death - traces of mechanical damage and asphyxia, poisoning, extreme temperatures, electricity and others) 8. Conclusion (underline): clinical death before the arrival of medical workers; biological death before the arrival of medical workers; death during medical care.
The medical history is kept every day. On the third day of illness, or if the patient is in the hospital for more than ten days or needs to be transferred to another doctor, a staged epicrisis is filled out, which describes the patient’s condition, the appointment of diagnostic tests therapeutic measures. The description may vary depending on the observation period during which it is filled out, the severity of the patient’s illness, and whether a diagnosis has been established or not. Conditions

  • If a diagnosis has not been made, then the epicrisis discusses the presumptive diagnosis and diagnostic measures to confirm it.
  • If the diagnosis has already been established, then the stage of the disease and its prognosis are described. The patient's complaints, laboratory and instrumental studies are described.
  • In the future, the stage-by-stage epicrisis describes the effectiveness of treatment, doses of basic medications, and changes in therapy.

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Document text:

Approved by order of the Ministry of Health dated November 17, 2009 N 1085

_______________________________________________ (name of the organization that issued the conclusion) Post-mortem epicrisis (conclusion on the death of a person who died outside a healthcare organization) 1. Last name, first name, patronymic _________________________________________________ 2. Date of birth "___" __________________ ______ 3. Address of place of residence (place of stay) ______________________________ ___________________________________________________________________________ 4. Место констатации смерти (осмотра трупа)________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Дата "____" ______________ 20___ г. время __________________ (часов) 5. В присутствии (указать) ________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 6. Известные обстоятельства смерти ________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 7. External inspection corpse (in order to establish visible signs of violent death - traces mechanical damage and asphyxia, poisoning, exposure to extreme temperatures, electricity and others) __________ _____________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ 8. Conclusion (underline): clinical death before the arrival of medical workers;

biological death before the arrival of medical workers;

  • death during medical care. Doctor (paramedic, physician assistant) _________________________ _______________ _____________________________ position signature initials, surname “_____” _________________ 20_____ I agree with the registration of the fact of death without an autopsy. ___________________________________________________________________________ (degree of relationship with the deceased, grounds for legal representation) _________________________ _____________ "___" ___________ 20___ initials, surname signature Internal Affairs officer (head of the investigative and operational group): There are no grounds for calling the investigative and operational group. ______________________ ___________ _____________________ position signature initials, surname "___" _________________ 20___ ___________ time

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Epicrisis is a generalized judgment of the attending physician or group of doctors about the patient’s state of health. It indicates the diagnosis, stages of the disease and the results of its treatment. All types of epicrisis, in principle, are similar to each other and differ in the final part, and the main content must correspond to the approved scheme.

The discharge summary is one of the most common documents in medical practice. Many similar stationary documents are directly related to it. Regardless of its type and individual features, the epicrisis is a conclusion about the reasons that led to the onset of the disease, the measures taken and the final diagnosis.

Features of the document

Depending on the patient’s condition and the measures taken, the discharge summary from the medical history may include the attending physician’s recommendations for the patient’s further recovery and indicate a number of restrictions for him in subsequent work activities. This document can serve as a valid basis for termination or partial release from heavy and specific work previously performed by the patient.

The discharge summary from the hospital can be entered into the medical history and various medical certificates. If the patient is being treated on an outpatient basis, then the doctor’s entry of the appropriate epicrisis into the chart will serve as a further impetus for his hospitalization. For example, data on the child’s medical history should be reflected not only in his chart, but also duplicated in the epicrisis after certain period- 1, 3, 5 years, and the last entry was at the age of 16, at the time of his transfer to an adult clinic.

In the medical history of inpatients, the discharge epicrisis is completed in mandatory to reflect all treatment measures taken and gradual changes in the patient’s condition during the entire period of hospitalization.

Types of epicrisis

Depending on the situation and condition of the patient, the document can be of several types:

  • staged;
  • posthumous;
  • translated;
  • discharge

A staged epicrisis is drawn up when the diagnosis is unclear, that is, the likelihood of a particular disease occurring. It reflects possible options treatment or complex preventive measures along with the results at each stage. As a rule, this document is issued every 7-14 days.

A post-mortem epicrisis is issued in the event of death in a medical institution. It indicates the cause of death of the patient and the actions of the resuscitation team to return the patient to life, with the obligatory indication of the reasons and factors for the ineffectiveness of the steps taken. The post-mortem epicrisis must strictly be accompanied by an autopsy report from a pathologist.

The form of the transfer epicrisis is practically no different from the discharge report; the only thing, among other things, that is indicated there is the reason for transferring the patient from one department or hospital to another.

Discharge summary in medical history

Both of these documents are closely interrelated and reflect the patient’s condition during hospitalization, during the period of treatment and at the final stage of discharge. The epicrisis also affects later life the patient, taking into account the illness he has suffered.

Some medical workers often pay the main attention to the patient’s medical history, and not to the epicrisis, since they need it to keep their records. There are often cases when a patient, after all treatment and preventive measures in a hospital or clinic, leaves a medical institution without having a discharge summary from the medical history.

A sample of this document is encoded in a specific font and designated as “Form 027/u”. This mark should appear in the upper right corner of the form in both manual and printed forms.

The difference between a medical history and an epicrisis

Medical history and discharge summary are medical certificates describing the progress of a patient’s treatment. History implies detailed and step-by-step description all procedures and the patient’s reactions to them. It is drawn up using medical terminology, which indicates a set of specific medications, the administered dosage, time and frequency of administration, and other important nuances.

After the patient is discharged, the medical history remains with the attending physician and is not given to the patient. To familiarize yourself with it, the patient or a third-party doctor must make an official request to the medical institution.

The discharge summary (sample form 027/у) is more general in nature, unlike the medical history, and does not require specific data to be indicated along with formatting in strict medical terminology. Rather, this is an annotation to the history, which will be useful when the patient subsequently seeks medical help, and the epicrisis can also serve as a valid reason for absence from work (for lack of sick leave).

Outpatient clinic

The discharge summary is of particular importance for outpatients who need help from another doctor or third party. medical institution, as well as for children who, with age, must transfer from pediatric department into an adult.

To summarize, it can be noted that the discharge summary is necessary for the patient so that he has an idea of ​​how he was treated, what diagnosis was made and how he should further plan his work activity and life in general.

Registration of epicrisis

Epicrisis of any type and type must include the following information:

  • FULL NAME. patient, year of birth, registration;
  • diagnosis;
  • the patient's main symptoms and complaints;
  • stages of the disease;
  • test results and opinion of the attending physician and related specialists.

If a clinical diagnosis is established, the attending physician substantiates it and provides medical evidence. In cases where the patient has been operated on or any surgical intervention has taken place, the document describes all processes in stages.

In any case, the discharge summary must contain a step-by-step course of treatment, reflecting the reasons and results of the doctors’ intervention and the use of certain methods of influencing the patient.

The importance of the epicrisis

Epicrisis is the most important medical document that allows doctors of various departments to “painlessly” exchange data. In addition, this document is a tool for monitoring the patient’s health status.

The epicrisis is especially important for those categories of patients whose problems relate to the cardiovascular system, oncology, mental health, tuberculosis and sexually transmitted diseases. Therefore, patients who have any relation to this group should pay attention to the presence of an epicrisis upon discharge.

It is also worth noting that the epicrisis is a medical document, the contents of which are not subject to public disclosure and are protected

The causes and development of the disease, the rationale and results of treatment, formulated upon completion of treatment or at a certain stage. Epicrisis is a mandatory component of medical records. Depending on the characteristics of the course and outcome of the disease, the epicrisis may include a judgment about the patient’s prognosis, a conclusion about the need for further monitoring of him, and treatment and occupational recommendations. In case of death, the epicrisis indicates the cause of death.

Types of epicrisis

The need to compile an epicrisis arises in different periods observation of the patient. An epicrisis is entered into the medical record of an outpatient patient in order to evaluate the results of medical examination (1-2 times a year), and also, if necessary, to justify the continuation of treatment when the patient is referred to a VKK and during hospitalization. An epicrisis in the form of medical observation results is added to the child’s developmental history when the child reaches the ages of 1, 3 and 7 years, as well as at 18 years old when the teenager is transferred to an adult clinic. In the medical record of an inpatient patient (medical history), epicrises reflect the results of the patient’s stay in the hospital every 10-14 days (stage epicrisis), when the patient is discharged from the hospital (discharge epicrisis), when he is transferred to another medical unit (transfer epicrisis), and in In case of death of the patient, a post-mortem epicrisis is compiled, which is subsequently supplemented by a pathological epicrisis.

All types of epicrisis contain:

  • passport part;
  • detailed clinical diagnosis;
  • complaints, most important information from the anamnesis about the main stages of the disease;
  • examination data confirming the diagnosis of both the underlying disease and its complications;
  • specialist consultations.

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Synonyms

    See what “Epicrisis” is in other dictionaries: - (from the Greek epikrisis decision), a doctor’s conclusion about the patient’s condition, diagnosis and prognosis of the disease, including medical and labor recommendations. It is recorded in the medical history every 10-14 days (staged epicrisis) and upon discharge from the hospital... ...

    Modern encyclopedia - (from the Greek epikrisis decision) a doctor’s conclusion about the patient’s condition, diagnosis and prognosis of the disease, including medical and labor recommendations. Recorded in the medical history every 10-14 days. (staged epicrisis) and upon discharge from the hospital... ...

    Big Encyclopedic Dictionary epicrisis - a, m. épicrise f., German. Epikrise gr. epi after + crisis solution. In medicine, the final conclusion regarding whose identity. illness (usually placed at the end of the medical history record). BAS 1. The autopsy is over. In his epicrisis, the pathologist stated that...

    Historical Dictionary of Gallicisms of the Russian Language Noun, number of synonyms: 1 conclusion (51) Dictionary of synonyms ASIS. V.N. Trishin. 2013…

    Synonym dictionary A; m. [from Greek. epi after and crisis decision, outcome] Honey. The final conclusion of the doctor, recorded in the medical history. * * * epicrisis (from the Greek epíkrisis decision), a doctor’s conclusion about the patient’s condition, diagnosis and prognosis of the disease, ... ...

    I Epicrisis (epicrisis; Greek epikrisis judgment, decision) a judgment about the patient’s condition, the diagnosis, the causes and development of the disease, the rationale and results of treatment, formulated upon completion of treatment or at a certain stage... Medical encyclopedia

    - (epi... gr. krisis decision) the final part of the medical history, containing the rationale for the final diagnosis and treatment, as well as medical. prognosis and treatment and prophylactic recommendations. New dictionary foreign words. by EdwART,… … Dictionary of foreign words of the Russian language

    - (epicrisis; Greek epikrisis judgment, decision) a judgment about the diagnosis, causes, pathogenesis of a disease and the results of its treatment, made after the end of treatment or a certain stage of it and recorded in medical records ... Big medical dictionary

    - (from the Greek epíkrisis decision, definition) a doctor’s conclusion containing information about the patient’s condition, diagnosis and prognosis of the disease, medical and work recommendations, etc. Recorded in the medical history (See Medical history) every 10 14 days ... Great Soviet Encyclopedia