Clinical Records

the basic medical document compiled for every patient who applies to a medical treatment and prevention center.

The clinical record contains a basic information section (family name, given name, patronymic, age, family status, occupation), information on previous diseases, data on current illness, and the results of examination and treatment. Changes in the patient’s condition and the course of his illness are entered in the clinical record at the polyclinic at each visit, and in the hospital, daily. In the event of the patient’s death, an official report of the pathologicoanatomic autopsy is included. When the patient is discharged or transferred to another medical institution, or in the event of his death, the general conclusions of the attending physician (the epicrisis) is entered. The clinical record ensures continuity in the application of therapeutic and preventive measures by all physicians who observe the patient. When necessary, the clinical record serves as material for legal and forensic inquiry.