1. Military rank, surname, name, patronymic of the patient who was treated in such and such a department, indicating the date and a detailed diagnosis.
2. General condition and nature of complaints upon admission.
3. Basic data from the anamnesis of the disease.
4. Causes of exacerbation of the disease if it is chronic.
5. Objective data (only pathology, results of laboratory and instrumental studies confirming this diagnosis are indicated).
6. Difficulties in diagnosis (briefly note that the patient underwent differential diagnosis with diseases such as …, and therefore the duration of hospitalization was longer.
7. Treatment performed (regime, diet, medication, including … (the total dose of antibiotics, hormones, cytostatics is indicated), the amount of blood transfused, physiotherapy and exercise therapy).
8. Evaluation of the effectiveness of treatment (as a result of treatment, the condition improved, pain and dyspeptic syndromes stopped, the ulcer healed, etc.).
9. Conclusion and recommendations of experts.
10. Recommendations of the attending physician (observe the regime of work and rest, avoid physical overload, diet No. 1 – with the restriction of spicy, fatty and salty foods, stop smoking, under the supervision of the doctor of the unit and the therapist of the clinic in spring and autumn for a month – taking multivitamins 1 tablet 3 times a day, vikalin 1 tab. 3 times a day, Almagel or a mixture of Bourget 1 tablespoon 3 times a day, etc.). Spa treatment.
11. Where to be discharged (to the unit or needs to be released for 3 days, submitted to the VVK, under what article, or to the clinic with a sick leave in case of treatment of thematic patients).
Signature of the head of the medical unit, the head of the department and the attending physician.
Example. The captain … was under examination and treatment in the pulmonology department … from … to … 19. .. due to infectious-allergic, hormonally dependent bronchial asthma, with frequent attacks of suffocation, respiratory failure of II degree. Upon admission, the patient complained of asthma attacks with sharply difficult expiration, paroxysmal cough with viscous mucous sputum, general weakness.
Suffering from bronchial asthma since … 19 …, the last exacerbation is associated with the irregular intake of prednisolone, which was recommended at a dose of 15 mg per day by a polyclinic therapist. Moderate condition, forced semi-sitting position, barrel-shaped chest with smoothed intercostal spaces. The respiratory rate is 24 per minute, percussion over the lungs there is a clear pulmonary sound with a box shade, shallow breathing with an extended exhalation, over the lungs over the entire surface, but large in the upper sections – dry, wheezing. Pulse – 105 beats per minute, rhythmic, clear heart sounds. BP – 130/80 mm Hg. Art., otherwise without features.
Examination by an allergist revealed hypersensitivity to house dust, intolerance to odors of cologne, perfume, and tobacco smoke. When x-rays of the chest, emphysema is noted, with spirography – a violation of the function of external respiration of the II degree of obstructive type, a positive test with ephedrine and berotek, with bronchoscopy – chronic atrophic bronchoadenitis. In the analysis of sputum – an increased number of eosinophils, Kurshman’s spiral.
As a result of treatment: regimen, diet, medication (intal, berotek, prednisolone inhalations (750 mg), diphenhydramine, expectorant mixture, calcium chloride according to the scheme, therapeutic lavage through a bronchoscope, physiotherapy and exercise therapy – the condition improved. In particular, asthma attacks disappeared, cough has significantly decreased, the dose of prednisolone is reduced to 5 mg per day.Discharged in a satisfactory condition.Needs to be released from duty for 3 days.It is recommended: to observe the regime of work and rest – avoid hypothermia, strong odors (perfume, tobacco smoke, kitchen); under the supervision of the doctor of the unit (therapist of the polyclinic), taking prednisolone 1/2 table 2 times a day after meals (drink with milk or almagel), inhalation of intal 1 capsule 3 times a day for 2 months, exercise therapy.
Head of Medical Unit
Note . When transferring from department to department, the patient must be examined by the head (resident) of the department where the patient is transferred, indicating the diagnosis and their consent to the transfer. All transfers of patients from one medical institution to another must be coordinated with the medical departments of the fleets and bases.
X. CONTENT OF THE DISCHARGE STATEMENT IN THE MEDICAL BOOK OR CERTIFICATE ISSUED TO THE PATIENT
1. Passport part.
2. Detailed diagnosis of the disease.
3. Analyzes in dynamics (general clinical, biochemical, etc.).
4. The content of the conclusions on the instrumental and prescribed research methods, indicating the nature of the pathological changes documenting them.
5. Conclusion and recommendations of consultants.
6. Conducted treatment and its effectiveness.
7. Recommendations and where to be discharged (the same as for the discharge epicrisis, drawn up in the medical history).
8. Signature of the head of the medical unit, the head of the department and the attending physician.
Note. If a certificate is issued without a medical book, then it should briefly reflect the general condition of the patient and his complaints upon admission, the history of the disease and the reasons for its development or exacerbation.
XI. POST-DEATH EPICRISIS
1. Registered in the form of a discharge summary, drawn up in the medical history, with the exception of the last three paragraphs. Instead, they provide data on the circumstances of death, the immediate cause of death and resuscitation.
Example. Despite the ongoing intensive therapy (5% glucose solution with panangin, lasix, strophanthin, vitamins, cocarboxylase was prescribed intravenously), the patient’s general condition continued to deteriorate progressively and in … cardiac and respiratory arrest occurred. Resuscitation measures (closed heart massage, transfer of the patient to controlled mechanical breathing, defibrillation of the heart, intracardiac administration of calcium chloride and adrenaline) did not bring any effect, and in … biological death was ascertained.
1) Upon admission in a moderate or severe condition with an unclear diagnosis, the patient should be examined by the leading specialist of the MH (head of the department) and reported to the head of the medical unit.
2) If a similar patient is treated during the first 1-3 days, and no positive effect is noted, it must be reported to the chief specialist of the fleet, about which an appropriate entry should be made in the diary.
3) The decision to discharge a patient from a medical institution, presentation to the IHC, the appointment of complex diagnostic studies, drugs with severe side effects (hormones, cytostatics, etc.), blood transfusions, a consultation, transfer to another department or institution must be agreed with the head branches and are held with his permission.
4) The head of the department is responsible for the correctness and completeness of keeping case histories, is obliged to personally check them, systematically conduct classes with the residents of the department, and analyze the defects made by them in keeping the case histories.
5) The command of medical institutions (the head, his deputy for the medical unit, leading specialists) is allowed to clarify, improve certain provisions of the case history. It is allowed to keep records in the medical history on uniform forms and in typewritten text.
6) Responsibility for the correct maintenance of medical records rests with the direct executors, and control – with the deputy heads of the MMG for the medical unit.
7) An examination conducted for the purpose of accumulating scientific information is specially stipulated in the medical history and is carried out only with the consent of the patient.
8) Complex, and especially invasive, research methods (bronchography, bronchoscopy, colonoscopy, spinal puncture, diagnostic laparoscopy, angiography of the kidneys, heart, brain, puncture liver biopsy, etc.) should be carried out under the following conditions:
a) if these studies are absolutely necessary;
b) if they are technically flawless;
c) if the risk of complications is taken into account in advance and the patient is warned about it.