Get Epicrisis Report

The Epicrisis Report is a critical document used for summarizing a patient's medical history and treatment upon discharge. This guide will provide you with clear and concise instructions to effectively complete the report online.

Follow the steps to fill out the Epicrisis Report.

1. Press the ‘Get Form’ button to obtain the Epicrisis Report and open it in the online editor.
2. Begin by entering the patient's name and surname in the designated fields. Ensure that the spelling is accurate and that the names are legible.
3. Next, fill in the father's name, birth date, ID card number, patient ID number, and insurance number as required. These details are essential for patient identification.
4. Indicate the patient's sex and nationality accurately. These fields help to ensure comprehensive record-keeping.
5. Provide the home address of the patient. This information is important for communication post-discharge.
6. Enter the admission date and discharge date. This will reflect the duration of the hospital stay.
7. Specify the department where the patient was admitted. This detail helps in accurately categorizing the report.
8. Describe the reason for admission. Provide a concise explanation of the medical condition that necessitated the hospital visit.
9. Document the patient’s medical history, family history, and any significant events leading to the current admission. This section is critical for understanding the context of treatment.
10. Fill in the physical examination findings, including test results. If a pathology report is available, attach it in this section.
11. Record the diagnosis using the appropriate ICD 10 code, which aids in standardized documentation of diseases.
12. List any drugs administered during the patient's stay, ensuring all medications are correctly noted.
13. Summarize the consultation results and the clinical course, including any operations performed and complications experienced, if applicable.
14. State the result of the treatment and where the patient is being sent post-discharge. Options may include home, another institution, or transport within the hospital.
15. Provide information that needs to be communicated to the patient and their family at discharge. This includes details on medications, dietary recommendations, activity levels, and any other important notes.
16. Set the control appointment date and provide the doctor's name and surname. Ensure the signature field is completed as required.
17. Finally, review all entered information for accuracy. You can save changes, download the report, print it, or share the completed form as needed.

Complete the Epicrisis Report online today and ensure efficient documentation of your medical history.