Medizinische Zusammenfassungen: Bestandteile, Zwecke und EHR-Formate

A medical summary is a concise, structured overview of a patient's healthcare encounters, typically prepared by the treating physician or a clinical assistant.

Core Components

• Patient Demographics: Name, DOB, MRN, contact info.
• Health History: Past illnesses, surgeries, hospitalizations, allergies, immunizations.
• Current Diagnoses: Active and resolved conditions (ICD-10 codes).
• Medication List: Current prescriptions, OTC, supplements, doses.
• Procedures/Interventions: Surgeries, endoscopies, imaging, therapies performed.
• Recent Encounters: Visit dates, providers, chief complaints, assessments, plans.
• Social/Behavioral Factors: Tobacco, alcohol, living situation, support system (if relevant).

Purpose

• Continuity of care across providers/settings.
• Referral communication.
• Insurance authorization & billing support.
• Patient education & shared decision-making.
• Quality reporting & population health analytics.

Often generated from EHR as a Continuity of Care Document (CCD) or Referral Summary.