The epicrisis It is the clinical summary, complete and detailed, that is carried out at the discharge of a previously hospitalized person. This summary provides information about the hospitalization process from the onset of the illness to its resolution. It is the equivalent of a medical discharge report.
It is the responsibility of the treating physician to write the epicrisis at the time of hospital discharge. This responsibility can only be delegated to professionals who were in relationship with the patient.
The clinical history of a patient has all the information regarding the state of health, current and past, of a person. During a hospitalization this document is useful both to know the reason for consultation or admission and the evolution of the clinical picture. Epicrisis synthesizes the clinical history based on the most relevant data contained there.
Like any medical record, the epicrisis is truthful, legal and confidential. The information it contains must be clear, consistent, reliable and verifiable due to its importance to the patient. It is a tool that allows subsequent medical guidance, based on recent and updated data.
Although the epicrisis respects the content and sequence of the data, there are variations in the formats and the writing style.
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There are many advantages of a well-performed epicrisis. The usefulness of epicrisis is related to the right of each individual to know their state of health and the procedures carried out to achieve their improvement or cure. At the time of discharge from a hospital, the patient has the right to obtain a medical report.
- Provides the patient with data regarding their disease and the treatments applied to achieve their cure or improvement.
- Reference source so that other doctors know the pathological history of an individual, as well as previous treatments.
- It is a useful instrument when establishing claims or lawsuits for malpractice (legal).
- It presents the suggestions and recommendations for outpatient treatment and health maintenance.
- It must be objective. The content of the epicrisis is based on the medical records provided by the medical history. It must not have false information or add additional content to that exposed in other documents.
- Clear exposure. Despite containing medical language, the content should be easy to interpret and understand.
- Coherent. The written sequence of events of the disease must be related to reality, in terms of evolution and chronology.
- Truthful. The data provided by the epicrisis must coincide with what was stated by the patient and the record made. The opinion of the doctors and their written evaluation must also be presented without alterations..
- Medical-legal document. Both the history and the epicrisis constitute the support of the medical act performed on each patient. Any legal action - such as a lawsuit - will take into account the information contained in these documents..
The epicrisis must be based on the data contained in the medical history. The content must be a faithful reflection of the data provided by the document, hence its objectivity; therefore, it does not admit changes or modifications. The preparation of the discharge medical report corresponds to the treating physician.
The document must be prepared in a format where the health institution is identified. The structure of the epicrisis must contain the correct identification of the patient, which includes full name, sex, age, identity card and residence address. It is important to record the date of discharge.
- Reason for consultation and summary of the disease.
- Provisional diagnosis with which he was admitted to the health center.
- Hospitalization time, indicating the exact date of admission and discharge
This explains in a synthesized way the course of the disease during hospitalization..
- Clinical status of the patient during hospitalization.
- Results of complementary medical examinations, such as laboratory, imaging and special tests.
- Changes in diagnoses due to additional evaluations or test results.
- Complications during the hospitalization period.
- Findings of other diseases or clinical conditions different from those that motivated admission
It covers the treatment received, taking into account the medical care and medications used; this treatment can be pharmacological and non-pharmacological.
Other procedures such as cures performed and minor surgery are included. In the case of surgeries, the type of intervention performed must be specified.
It includes medical judgment or conclusions after hospitalization. This establishes the final result of the patient's state of health:
- Total healing.
- Partial cure.
- Persistence of the clinical picture or its consideration as a chronic process.
- Prognosis, if there is no improvement or it is a chronic disease.
- Pharmacological, stating the temporary or permanent medication to be received.
- Non-pharmacological. Diets, physical activity recommendations, rest regimen.
- Subsequent medical consultations, at the expense of the treating doctor or service. This is done to verify the health status after discharge.
- Referral to specialists, which occurs in the case of diseases diagnosed in the hospitalization period.
- Physical therapy and rehabilitation, when required.
- Temporary or permanent disability. The conclusion corresponding to the physical or mental sequelae of the disease.
At the end, the report must include the identification of the treating physician, his autograph signature as well as the pertinent data of his professional qualification. The stamp and signature of the institution's management will be the endorsement of the report made.
Patient: Juan Pérez
Age: 40 years
ID: 18181818
Date: 06/16/2018
Address: Main street # 12. Independencia Avenue. The city of origin.
Reason for consultation: abdominal pain, nausea, vomiting, thermal rise.
Current disease: A 40-year-old male patient who consulted for a 3-day-old illness characterized by severe abdominal pain in the epigastrium, radiating to the right iliac fossa within a few hours, accompanied from the beginning by nausea-vomiting and rising thermal not quantified, so he went to this center.
1- Acute surgical abdomen.
2- Acute appendicitis.
Date of admittance: 06/14/2018
Date of discharge: 06/16/2018
Hospitalization days: 3
Patient who had persistent symptoms since admission. Absolute diet, hydration, paraclinical examinations and evaluation by surgery are indicated. Laboratories conclude leukocytosis with a count of 18,000 x mm3 with frank deviation to the right.
The surgical evaluation confirms the diagnosis of acute appendicitis, for which an emergency preoperative evaluation and surgery are requested..
Postoperative without complications. Cardiovascular evaluation shows high blood pressure figures, which remained until yesterday, meriting antihypertensives.
For today, improvement of the clinical picture, so discharge is decided.
Surgical: McBourney technique appendectomy.
Pharmacological: Antibiotic therapy, hypertensive, hydration + gastric protection.
Patient with clinical improvement after the intervention performed, without complications in the immediate postoperative period. Tolerates food. You must go to cardiology control as soon as possible.
1- Immediate postoperative period of appendectomy.
2- Arterial hypertension.
- Antibiotic treatment for 7 days. Analgesics only in case of pain.
- Soft diet until medical control. Daily healing of the operative wound.
- Physical rest for 1 month.
- Medical control in 10 days.
- Go to an internal medicine or cardiology consultation for blood pressure control.
Treating physician
Schedule 20202020
Carnet N ° 131313
Health registration 2323
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