Notice epicrisis was introduced into the structure of the standard medical history not so long ago. At the same time, it is printed in several copies. One copy is pasted into the medical history, and the other is given to the patient.
Why do I need an excerpt from the medical history?
This document was put into use in order to facilitate the transfer of information between hospitals. This connection is most easily traced between hospitals and clinics. After a person has undergone a course of treatment in the hospital, he will be issued an discharge epicrisis. In the future, he goes with him to the polyclinic for medical care in which he is a member. Epicrisis is glued to outpatient card this patient. At the same time, the doctor of the clinic examines what diagnosis the patient was in the hospital with, if necessary, then puts him on the dispensary account.
What is the form of discharge epicrisis?
There is currently no single correct template for this document. Each healthcare institution chooses it on its own. At the same time, there are certain general rules by which a written epicrisis must be filled. The sample, regardless of the hospital, should include the following information:
- data on the patient and the time of his stay in the hospital;
- the name of the institution and department that carried out the treatment;
- research data;
- additional consultations of specialists;
- final diagnosis;
- data on the treatment;
- recommendations;
- surname and initials of the head of the department and the specialist who conducted the treatment.
Where may an emergency epicrisis be needed in addition to the clinic?
Patients who often seek medical care in hospitals already know that copies of epicrisis will not interfere with the attending physician. That is why during hospitalization they take them with them along with a passport and other documents. The fact is that all the diagnoses available to the patient include precisely the written out epicrisis. An example of such behavior will be positively received by any specialist, because thanks to the information contained in this document, the risk of medical error is significantly reduced. This is beneficial to both the patient and the doctor.
Another case where extracts from hospitals are needed, especially those whose prescription does not exceed 12 months, is the registration of a person for a disability group. Moreover, the originals are required here. Since the specialists in the clinic are engaged in the direction of medical and social examination on this issue, then you should not worry about this.
How is epicrisis created?
Most often, this document is typed by the attending physician on a computer. At the same time, the doctor spends a lot of time that he could spend on improving his own skills. It is for this reason that a department is gradually being included in the structure of hospitals, in which specialists in typing work. Their work can be built on several options. The first of them is the dictation of the epicrisis by the attending physician on the recording device. In the future, it is transferred to the typing department, and there, specialists, listening to the recording, print out an epicrisis. The second option involves simply filling out a medical history with the attending physician and then transmitting it to typesetters. After the epicrisis is typed and printed, it, together with the story, is transferred to the doctor for signature.
How long does an epicrisis take?
In most centers, this document is issued to the patient immediately after discharge. At the same time, according to the standards, an epicrisis can be prepared within 3 working days.In the future, the patient either comes and picks up the document himself, or, having agreed in advance with the doctor, receives it by mail. Currently, a new version of discharge epicrisis is being developed - electronic. As a result, a document certified with a special electronic signature can be sent directly to the patient’s mail. The convenience of this option is that if you lose the epicrisis, you can simply print it again.
In many departments involved in the treatment of patients with chronic diseases, a special archive is created, which includes discharge epicrisis of all patients previously treated in this institution. At the same time, it will be much easier for the doctor not only to fill out a repeated epicrisis, but also to prescribe a rational course of treatment. In addition, some research methods can not be repeated, which is convenient for both the patient and the doctor.
Immediate benefit for the patient
Many believe that this document does not have any value for the patient himself, but is designed to transfer data from one doctor to another. At the same time, one should not forget that any form of discharge epicrisis, in whatever medical institution it is filled, presupposes the presence of the column “Recommendations”. There, the doctor who was directly involved in the treatment of the patient leaves instructions for him on specific drugs, dosages and the frequency of taking medications. All this information will be extremely important for a person who has just written out, because it will help him consolidate the positive effect that was achieved as a result of inpatient treatment. This is especially useful for those who do not have any medical knowledge, because most are unlikely to remember the doctor's instructions by ear.
But I don’t have the opportunity to come to their clinic, I’m now in another city, for the same reason I don’t continue treatment with them.
The road to the hospital will cost me 50t.r. (Norilsk-Moscow) epicrisis may be done more than one day, plus a hotel !! And how can I be .. ?? !!!! ???