Department of education and science of Ukraine
Sumy state university
MEDICAL INSTITUTE
DEPARTMENT OF INFECTIOUS DISEASES AND EPIDEMIOLOGY
Methodical recommendations
To the inspection of infectious patient
And writing of academical hospital chart
for doctors, interns, students of senior courses of higher medical establishments of education III-IV level of accreditation
Sumy
Methodical recommendations to the inspection of infectious patient and writing of academical hospital chart / Compilers: M.D. Chemich, N.I. Ilina, V.V. Zahlebaeva, A.I. Piddubna – Sumy: Sumy State university publishing house, 2008. – 31 s.
Department of infectious diseases and epidemiology
| Actuality and rules of the curatio conducting............. | |
| Title page........................ | |
| Passport part....................... | |
| Complaints of the patient......................... | |
| Anamnesis of disease...................... | |
| Epidemiology anamnesis................... | |
| Allergist anamnesis...................... | |
| Anamnesis of life.......................... | |
| Objective inspection of the patient.................. | |
| Previous diagnosis and its justification................ | |
| Plan of the additional inspection.................... | |
| Plan of the medical treatment.......................... | |
| Data of laboratory and instrumental methods of research.... | |
| Diary.......................... | |
| Differential diagnosis.................... | |
| Final diagnosis........................ | |
| Medical treatment and prophylaxis..................... | |
| Features of illness progress at a patient........... | |
| Prognosis and its justification.................... | |
| Epicrisis.............................. | |
| Used literature..................... | |
| Addition............................. | |
| List of literature.................. |
TABLE OF CONTENTS
Actuality and rules of the curatio conducting
The conduct of hospital chart is inalienable part of everyday doctor’s work. In a hospital chart a doctor fixs the supervisions after the dynamics of disease, efficiency of medical treatment. It is the creative result of activity of doctor bedside sick. The purpose of conducting of curatio in the clinic of infectious diseases is development at the future doctors of clinical thought, ability to use in practice theoretical knowledges during the decision of tasks diagnostic and medical, and teaching of bases of deontologii, ability of intercourse with a patient, education of attentive, sensitive, patient attitude toward a sick man.
During curatio future doctors fasten practical skills from the complete inspection of sick, which provides for: anamnesis, inspection, conducting of differential diagnosis. An academic hospital chart represents ability of student consistently to study all information about a patient, correctly to argue and formulate a diagnosis, to conduct justification of differential diagnostics, to put logically a final diagnosis, to appoint adequate medical treatment.
Writing of hospital chart foresees the obligatory study of additional literature, that touches this and diseases look like with it.
During the employments taken on curatio, a future doctor looks after a patient, fixing the changes in a state of his health in diaries. On the first employment with curatio a teacher fastens a patient after a future doctor. A counsel is under an obligation to collect anamnesis, to conduct the inspection of sick, justificate previous diagnosis, to draw up a plan of inspection and medical treatment.
On subsequent employments future doctors meet with the hospital chart filled by a treating doctor, the results of laboratory and instrumental methods of research are written, a differential diagnosis is discussed together with a teacher. On the basis of analysis and synthesis of data anamnesis, epidemiology, clinical, laboratory and instrumental a final diagnosis is formulated and medical treatment of sick is corrected.
After curatio a future doctor hands over to the teacher the designed hospital chart for verification. Defence of hospital chart is adopted by the manager of department or associate of a professor in presence a teacher and all group.
A hospital chart is designed pursuant to the resulted chart, must be written in time, legibly and neatly. If a future doctor did not lick put problems, a new patient for curatio in off-hour time is offered him.
