How to write a discharge summary

Epicrisis is an extract from a medical card. It shows the whole dynamics of the condition and treatment of the patient during the period of stay in hospital. Epicrisis can be graded, discharge, transfer, and postmortem pathology.

Instruction

1. When finding a patient in the hospital for a long time every 10-14 days to fill a landmark epicrisis. Specify the date and time of receipt of the patient, his complaints. Describe details of medical history, i.e. how and when the patient became ill, as he changed his condition from the onset of the disease before admission to hospital. Further describe the data obtained in the examination and laboratory-instrumental examination. Specify only those data that confirm your diagnosis. Record the treatment received by a patient. Finish landmark epicrisis description of medical events, upcoming patient in the future.
2. When the patient's discharge from hospital complete medical report. Start with the date of admission and date of discharge. Then, in the same way as in a landmark epicrisis specify complaints at admission, medical history, findings and treatment. If the patient was operated, specify the name of the operation. Finish the medical report by saying that the patient's condition as a result of the treatment have improved. Write down the recommendations that you gave Picanto at discharge (medication, monitoring the local therapist, etc.).
3. When transferring a patient from one ward to another within the same medical institution or from one hospital to another complete transfer case history. Write it in the same way as discharge. Complete the discharge summary explanation of the reasons for transfer.
4. In the case of death of the patient during treatment, complete postmortem epicrisis. Reflect in the complaint at admission, medical history, data of examinations and laboratory and instrumental studies of the dynamics of deterioration. Then describe the cause and circumstances of death. Finish posthumous posthumous epicrisis the unfolded clinical diagnosis.
5. Pathoanatomical epicrisis to be completed after the autopsy as a pathologist. It describes the mechanism of death in this patient (tanatogenesis). Comparison of in vivo studies and data collected at autopsy. Ends pathoanatomical epicrisis detailed pathoanatomical diagnosis.