Document structure
Maintaining a medical history is subject to strict regulations. It records the course of the pathology from primary complaints to the outcome of treatment.
The mandatory framework of the document includes:
- Title page (patient identification data).
- Admitting physician's examination.
- Initial examination by the attending specialist physician.
- Observation notes (progress notes), reflecting day-to-day changes.
- Examination results (instrumental, laboratory data) and consultations from specialists.
- Epicrisis — a summarizing judgment on the prognosis and diagnosis (stage or discharge summary).
Logic and diagnosis standardization
Making a diagnosis is the result of a deep analysis of pathogenesis and the connection of symptoms with environmental factors. The physician conducts a differential search: compares facts, filters out accidental coincidences, and separates symptoms into key and doubtful ones.
A detailed clinical diagnosis must consist of:
- The name of the nosology with the identification of leading syndromes.
- The phase of the course (exacerbation or remission for chronic processes).
- Functional diagnosis (assessment of the degree of organ dysfunction).
- Indication of complications (e.g., bleeding secondary to peptic ulcer disease).
To standardize the work of physicians and collect homogeneous statistics at national and international levels, diagnoses are aligned with ICD-10 (International Classification of Diseases, 10th Revision).
Daily curation and progress notes
Progress notes reflect the daily observation of the patient in the department. Their main task is to show the dynamics of the process.
- Vocabulary: The description should be vivid. The physician should use active verbs ("increases", "decreased", "disappeared"). The use of stereotyped static phrases ("complaints are the same", "condition is unchanged") is discouraged.
- Content: The records capture the evolution of complaints, changes during physical examination of organs, and newly emerged additions to the anamnesis. The physician also provides a clinical interpretation of the internal picture of the disease, analyzes the tolerability of therapy (presence of side effects), and the effectiveness of treatment.
Graphic representation and temperature sheet
Graphs are used for clear visualization of the course of the disease. Data already interpreted by the physician are plotted on them, changing the time scale depending on the duration of the disease (from years to days of the current hospitalization).
The main graphic addition to the history is the temperature sheet. It is filled out in parallel with the progress notes and contains:
- Charts: temperature curve (morning and evening), blood pressure, pulse (marked in red).
- Digital values in text: body weight, respiratory rate (RR), stool frequency, fluid intake, and daily diuresis (water balance).
- Key markers: appearance of significant symptoms (rashes, bleeding, edema) and main therapeutic orders.
Single instrumental examinations (angiography, ultrasound, endoscopy) can also be recorded on the timeline, while all medications and procedures are prescribed in a separate prescription sheet.
Types of epicrisis
An epicrisis is a judgment on the patient's condition, diagnosis, and prognosis.
- Stage epicrisis: written every 7–10 days to assess dynamics over the past period, plan new examinations, and adjust tactics.
- Discharge summary: summarizes the hospitalization. Contains the final diagnosis with detailed argumentation (especially if the case presented diagnostic difficulties), brief anamnesis, important examination findings, description of treatment, and changes by the time of discharge. Finally, treatment and preventive recommendations are given, and working capacity is assessed.
Sometimes the diagnosis is justified based on the effectiveness of treatment (ex juvantibus therapy), for example, if the pain is atypical but relieved by nitrates, confirming CAD. Upon issuing the discharge summary, the physician is obliged to explain all recommendations orally and in detail to the patient.
Briefly: answers to topical questions
What are the types of temperature curves (types of fevers)?
The following types of temperature curves are distinguished:
- Continuous fever (febris continua) — high temperature level; daily fluctuations do not exceed 1 °C.
- Remittent fever (febris remittens) — high body temperature; daily fluctuations are 1–2 °C, temperature does not drop to normal values.
- Intermittent fever (febris intermittens) — daily fluctuations of 1–2 °C; temperature may normalize for several hours followed by a new rise.
- Hectic (wasting) fever — repeated daily temperature fluctuations of more than 2–3 °C with rapid drops.
- Irregular fever — absence of any pattern in temperature fluctuations.
- Inverted fever — disruption of the normal circadian rhythm: morning body temperature is higher than evening temperature.
What are the main sections of the patient interviewing scheme (subjective examination)?
The patient interviewing scheme includes the following sections:
- Complaints — main complaints have the greatest subjective significance for the patient; additional complaints are revealed during active questioning. The physician also asks questions about general symptoms: weakness, fever, chills, headaches, irritability, changes in appetite, thirst, and body weight.
- History of the present illness (anamnesis morbi).
- Past medical history (anamnesis vitae), including previous diseases. When inquiring about past diseases, not only the fact of the illness is clarified, but also the features of its course, in order to identify chronic pathological processes that may affect the patient's current condition or have a pathogenetic connection with the present illness.
- The structure of the anamnesis also includes symptoms and treatment methods.
What is the standard sequence of physical (objective) examination methods for a patient?
The standard sequence of physical examination is based on the principle "from simple to complex".
- Inspection / Observation (visus) — the first stage, starting with general and local inspection (assessment of the skin and general status).
- Palpation (palpatio) — a method based on touch to assess tissue properties.
- Percussion (percussio) — performed following palpation.
- Auscultation (auscultatio) — the final stage, performed strictly after taking the anamnesis, inspection, palpation, and percussion.
Class and exam questions
What is the difference between a stage epicrisis and a discharge epicrisis?
A stage epicrisis is drawn up every 7–10 days of hospital stay to evaluate intermediate treatment results and adjust the treatment plan. A discharge epicrisis is compiled at the end of hospitalization: it summarizes the final diagnosis, treatment administered, and contains recommendations.
What must be included in an expanded clinical diagnosis?
It includes an indication of the phase of the disease (for chronic processes), leading syndromes, functional diagnosis (degree of organ dysfunction), and a list of complications. The entire formulation must comply with ICD-10.
What words should be avoided when writing a progress note?
Physicians should avoid static and uninformative phrases such as "condition unchanged" or "complaints the same". Instead, active verbs highlighting the dynamics of changes should be used: "improved", "increasing", "resolved".
What else to study on this topic
- Symptom selection and syndromic justification of the diagnosis
- Diagnosis argumentation in atypical presentation (clinical example of CAD)
- Therapia ex juvantibus in differential diagnosis
- Assessment of water balance and diuresis in the temperature chart
- Rules for maintaining the medical prescription sheet
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