When an epicrisis is drawn up
The document is not written arbitrarily; there are strict indications for its compilation, concluding a specific stage of patient care. In surgical (and any other) practice, an epicrisis must be completed in three key situations:
- Upon discharge of the patient from the hospital (discharge epicrisis), when treatment is complete or the patient is transferred to outpatient care.
- Upon transfer to another medical institution (transfer epicrisis), so that the doctors of the receiving hospital have a complete understanding of the work done.
- In the event of the patient's death (death epicrisis), which becomes a crucial medical and legal document.
Patient details and diagnosis
Any medical conclusion begins with chronology. First of all, it is necessary to record the hospitalization dates, namely the exact date of the person's admission to the clinic and the total duration (period) of their stay in the hospital bed.
This is followed by a fundamental section — the detailed clinical diagnosis. It cannot simply be the name of the disease, but must have a clear structure:
- Primary disease. Indicates the nosology itself and mandatory its stage.
- Complications. Lists all pathological conditions triggered by the primary disease (this is especially important in surgery).
- Concomitant pathology. All other diseases that the patient has, but which are not directly related to the primary reason for hospitalization.
Justification of the diagnosis
The diagnosis in the epicrisis must not be unsubstantiated. The physician is obliged to provide a reasoned justification, relying on the data collected during treatment. This block includes a sequential listing of the evidence base:
- Indication of main symptoms identified in the patient.
- Results of laboratory and instrumental examinations.
- Data from functional studies reflecting the work of organs and systems.
- Data from morphological examinations. This includes the results of cytologic and histologic study of biopsy material, which is the gold standard of diagnostics in surgery and oncology.
Treatment and postoperative course
This section describes the entire therapeutic process in detail, but without unnecessary fluff. First of all, performed surgeries are recorded (name, date, scope).
Then additional treatment received by the patient is detailed:
- Antibiotic therapy.
- Immunotherapy.
- Physiotherapy procedures.
Extremely important for the surgeon is the description of the postoperative course. The doctor is obliged to indicate how the recovery period proceeded and must record all complications that arose, if any.
Outcome, recommendations, and mortality
The concluding part of the epicrisis describes the patient's status at the end of treatment. The patient's current condition upon discharge is assessed, and a clear evaluation of their work capacity is given (whether they can return to work or need sick leave/disability).
It is mandatory to prescribe recommendations for further treatment, which include:
- Prescribed medications.
- Necessary diet.
- Methods of exercise therapy (physiotherapy exercises).
- Indications for sanatorium-resort treatment.
- Need for further follow-up by specialists in related fields.
Features in case of a fatal outcome: If the patient has died, after a detailed description of the entire course of the disease, the epicrisis must formulate and indicate the immediate cause of death of the patient.
Briefly: answers to topical questions
Within what timeframe is the attending physician required to draw up a stage epicrisis during a patient's prolonged stay in the hospital?
A stage epicrisis is drawn up every 7–10 days of the patient's stay in the hospital. It is a mandatory section of the inpatient medical history and is filled out during the treatment process.
The main tasks of this document include:
- Assessment of dynamics — analysis of the condition over the past period.
- Planning — determination of further diagnostic studies.
- Correction — modification of treatment tactics.
What data from the post-mortem autopsy are entered into the final death epicrisis?
In case of a fatal outcome, the epicrisis must include the immediate cause of the patient's death. The section "Conclusion on the cause of death" indicates:
- Underlying cause of death — the disease or injury that initiated the train of morbid events leading directly to death; in the diagnosis, it acts as the primary disease and comes first.
- Immediate cause of death — arises as a result of a complication of the primary disease.
To remember the structure of the epicrisis, use the "6 D's Rule": Dates, Diagnosis, Documentation (justification), Deeds (treatment and surgery), Dynamics (condition upon discharge), Directions (further recommendations).
Class and exam questions
In which cases is compiling an epicrisis mandatory?
An epicrisis is completed in three cases: upon discharge of the patient home, upon their transfer to another medical institution, as well as in the event of a fatal outcome.
What parts does a detailed clinical diagnosis in the epicrisis consist of?
It must include the primary disease indicating its stage, all complications of the primary disease, and existing concomitant pathology.
What must be indicated in the epicrisis if the patient has died?
In the event of a fatal outcome, in addition to the standard description of the course of the disease and the treatment provided, the physician must clearly indicate the immediate cause of the patient's death.
What else to study on this topic
- Criteria for assessing work capacity upon discharge of a surgical patient
- Registration of histological and cytological conclusions in the medical record
- Classification of complications of the primary disease
- Principles of Diet and Exercise Therapy in the Postoperative Period
- Legal Significance of the Postmortem Epicrisis
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Other Topics in «CHAPTER 9. EXAMINATION OF THE SURGICAL PATIENT»
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