{"id":10735,"date":"2024-12-11T14:30:39","date_gmt":"2024-12-11T13:30:39","guid":{"rendered":"https:\/\/extali.eu\/docs\/4-informationswesen\/4-1-dokumentation\/4-1-12-patientenbezogene-berichte-arztbrief\/"},"modified":"2024-12-16T23:38:42","modified_gmt":"2024-12-16T22:38:42","slug":"4-1-12-patient-related-reports-doctors-letter","status":"publish","type":"docs","link":"https:\/\/gutehospitalpraxis.de\/en\/handbuch\/4-informationswesen\/4-1-dokumentation\/4-1-12-patientenbezogene-berichte-arztbrief\/","title":{"rendered":"4.1.12 Patient-related reports, doctor's letter"},"content":{"rendered":"
Download the VA as PDF <\/a>Download<\/a><\/div>\n\n\n\n

Goal and purpose<\/h2>\n\n\n\n

Reports should be forwarded in a timely manner to the departments inside and outside the hospital that are responsible for the patient's treatment or care. As a summarising document, the discharge letter is of great communicative importance. Rules must be established for its content and technical preparation.<\/p>\n\n\n\n

The report should always contain the reason for the patient's admission or referral, the diagnosis, the examinations and treatment procedures carried out and their results, the medication prescriptions and a description of the patient's state of health at the time of referral.<\/p>\n\n\n\n

The discharge letter should also include the concomitant illnesses, the medication taken during the hospitalisation, a description of the course of the illness and a description of the patient's condition on discharge (improved, unchanged), recommendations for further treatment and a plan for follow-up.<\/p>\n\n\n\n

The discharge letter (epicrisis) must be drawn up by an appropriately qualified person.<\/p>\n\n\n\n

Application<\/h2>\n\n\n\n

<\/p>\n\n\n\n

Description of the process<\/h2>\n\n\n\n

<\/p>\n\n\n\n

Risks<\/h2>\n\n\n\n

<\/p>\n\n\n\n

Resources <\/h2>\n\n\n\n

Material<\/h4>\n\n\n\n

Time required<\/h4>\n\n\n\n

<\/p>\n\n\n\n

Documentation<\/h2>\n\n\n\n

<\/p>\n\n\n\n

Responsibility and qualification<\/h2>\n\n\n\n

<\/p>\n\n\n\n

Notes and comments<\/h2>\n\n\n\n

<\/p>\n\n\n\n

Applicable documents<\/h2>\n\n\n\n

Validation documents<\/h4>\n\n\n\n

Terms<\/h4>\n\n\n\n

<\/p>\n\n\n\n

Attachments<\/h2>\n\n\n\n
Form for a doctor's letter<\/a>Download<\/a><\/div>\n\n\n\n
Sample for a doctor's letter<\/a>Download<\/a><\/div>\n\n\n\n

<\/p>","protected":false},"excerpt":{"rendered":"

Ziel und Zweck Berichte sollen zeitgerecht an die Stellen im und au\u00dferhalb des Krankenhauses weitergeleitet werden, die f\u00fcr die Behandlung oder Versorgung der Patienten Verantwortung \u00fcbernehmen. Der Entlassungsbrief hat als zusammenfassendes Dokument gro\u00dfe kommunikative Bedeutung. F\u00fcr die inhaltliche und technische Erstellung sind Regeln aufzustellen. Der Bericht soll immer den Grund f\u00fcr die Aufnahme oder \u00dcberweisung […]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":10711,"menu_order":12,"comment_status":"open","ping_status":"closed","template":"","doc_tag":[],"doc_badge":[],"class_list":["post-10735","docs","type-docs","status-publish","hentry","no-post-thumbnail"],"acf":[],"author_avatar":"https:\/\/secure.gravatar.com\/avatar\/c6b2616140d9fcd6a1c5d6d2ebbf43422308c9322c032ef03f88ec3235855dcf?s=96&d=mm&r=g","author_name":"admin","_links":{"self":[{"href":"https:\/\/gutehospitalpraxis.de\/en\/wp-json\/wp\/v2\/docs\/10735","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/gutehospitalpraxis.de\/en\/wp-json\/wp\/v2\/docs"}],"about":[{"href":"https:\/\/gutehospitalpraxis.de\/en\/wp-json\/wp\/v2\/types\/docs"}],"author":[{"embeddable":true,"href":"https:\/\/gutehospitalpraxis.de\/en\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/gutehospitalpraxis.de\/en\/wp-json\/wp\/v2\/comments?post=10735"}],"version-history":[{"count":0,"href":"https:\/\/gutehospitalpraxis.de\/en\/wp-json\/wp\/v2\/docs\/10735\/revisions"}],"up":[{"embeddable":true,"href":"https:\/\/gutehospitalpraxis.de\/en\/wp-json\/wp\/v2\/docs\/10711"}],"wp:attachment":[{"href":"https:\/\/gutehospitalpraxis.de\/en\/wp-json\/wp\/v2\/media?parent=10735"}],"wp:term":[{"taxonomy":"doc_tag","embeddable":true,"href":"https:\/\/gutehospitalpraxis.de\/en\/wp-json\/wp\/v2\/doc_tag?post=10735"},{"taxonomy":"doc_badge","embeddable":true,"href":"https:\/\/gutehospitalpraxis.de\/en\/wp-json\/wp\/v2\/doc_badge?post=10735"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}