EPICRISIS

From Big Medical Encyclopedia

EPIKRYZ (epicrisis; Greek epi-krisis judgment, the decision) — judgment of a condition of the patient, the diagnosis of a disease, the reasons of its emergence, development and results of treatment which is formulated upon completion of treatment or at its certain stage. AA. is an obligatory part of medical registration documents. Depending on features of a current and outcome of the disease the epicrisis can include judgment of its

forecast, the conclusion about is necessary pave further overseeing by the patient, activity therapy recommendations. At a lethal outcome in E. specify causes of death.

Need for drawing up E. arises during the different periods of observation of the patient. In the medical record of an ambulatory E. enter in case of the direction of the patient on VVK, at hospitalization and for the purpose of assessment of results of medical examination (1 — 2 time a year). (See) an epicrisis in the form of results of medical observation bring in history of development of the child on reaching the child of age 1; 3 and 7 years, and also in 15 years at transfer of the teenager from children's policlinic in adult. At stay of the patient in a hospital E. (see) bring in a case history each 10 — 14 days (stage E.), at an extract of the patient from a hospital (vypisny E.), at its transfer in another to lay down. division (translated E.) or at approach of death (posthumous E.).

Vypisna E. contains a passport part, the developed wedge, the diagnosis and its justification by data of the anamnesis and results of inspection; data on the carried-out treatment, its results with reflection of the most important elements of course of disease and an objective condition of the patient; conclusion about an outcome of a disease; to lay down. - the prof. of the recommendation. V E. specify all symptoms of a disease and data of additional methods of inspection confirming the diagnosis (see) both basic disease, and its complications. The carried-out treatment is stated and estimated on stages. The conclusion about an outcome of a disease is drawn in one of the following formulations: recovery, incomplete recovery, improvement, a state without changes, transition of a disease from an acute form in chronic, an aggravation of symptoms. At incomplete recovery make the forecast (see), make recommendations about the further mode and treatment of the patient, make assessment of his working capacity in relation to a profession and working conditions on the following categories: restriction

of working capacity, transition to easier work is shown, transfer into disability is necessary. A final assessment of working capacity is given and approved by VTEK.

If to the patient an operative measure, in vypisny E is made. specify a type of anesthesia, character and the course of operation, its results. In obstetric practice vypisny E. contains data on pregnancy, the course of childbirth, obstetric aid, a current of a puerperal period; data on the child, including a current of the post-natal period and a condition of the newborn by the time of an extract. At an extract of the patient who transferred inf. a disease, in E. bring epidemiol. the anamnesis, the possible and come contacts with inf. patients and other factors.

Translated E. differs from vypisny only in a final part where specify the reason of transfer in another to lay down. division.

Stage E. make according to the scheme vypisny E., but according to contents it can vary more widely depending on the period of overseeing by the patient. At the obscure diagnosis in stage E., as a rule, give diagnostic hypotheses, plan additional diagnostic testings; estimate efficiency of the carried-out treatment. At the established diagnosis stage E. contains justification of the diagnosis, judgment of a stage of a course of a disease, option of its current, etc. In the subsequent stage E. estimate efficiency to lay down. actions, proving need of their continuation or change.

In posthumous E. enter supplied the anamnesis, the information on an objective condition of the patient, additional methods of inspection and to lay down. actions, describe and analyze a condition of the patient before death, express opinion on a proximate cause of death, establish a final wedge, the diagnosis. The pathoanatomical diagnosis is made out in pathoanatomical E., the Crimea complete the protocol of opening; it is also placed in a case history of the dead. Clinical and pathoanatomical diagnoses are compared by the expert person which is making out final E. At the same time note full coincidence or discrepancy of the specified diagnoses, neustanovle-ny causes of death, analyze the objective and subjective reasons of a diagnostic mistake, correctness to lay down. actions and веде-^ a niya of records in the history of a disease.

AA., being one of forms of communication between medical institutions, promotes improvement of succession in questions of diagnosis of a disease and treatment of the patient. Succession in overseeing by the patients having cardiovascular diseases, oncological, mental, venereal diseases and tuberculosis is especially strictly controlled. In itself 3. does not grant any social rights to the patient, napr, release from work, receiving group of disability. However the data stated in it are the basis for execution of various documents of a legal harakte-ter: dignity. - hens. cards, a messenger leaf on VTEK, the certificate of release from nek-ry types of works.

Contents E. well only to medics, and rules of observance of a professional (medical) secrecy extend to it. Sick bring to the attention only the diagnosis of a disease and lechebnotrudovy recommendations. The epicrisis is stored in medical establishment (in the medical card of the inpatient or in the medical card of an ambulatory) and sent to other medical institutions on special communication channels or by mail. The epicrisis can matter the legal document in court to.-medical practice.

E. I. Sokolov, T. A. Polosova.

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