Making a prognosis

The final statement in the formulation should be the prognosis. This attempt to predict what will happen to the patient in the future should be expressed as clear statements about likely outcomes, avoiding vague comments such as 'the prognosis is guarded' (found all too often in case records). The patient and family usually hope to be told about the prospects for recovery and the likelihood of relapse. Efforts should be made to do this, but with due care to emphasize that a prognosis is only an estimate that may be proved wrong by events.. The ideal prognosis should contain predictions of such things as:

1. immediate response to treatment, assuming compliance;

2. duration of this episode of illness and/or stay in hospital;

3. degree of recovery from this illness (i.e. partial or complete) in terms of both symptoms and return to previous activities;

4. risk of recurrence, stated as the likely position at specific points in time, depending upon the circumstances of the case (6 months, 1 year, and 2 years from the present are often appropriate).

However difficult it may seem, attempts should be made to record a prognosis in these terms, and to sign it. To do this will fulfil the legitimate expectations of the patient and family, and the clinician will make possible a uniquely valuable learning experience when faced in the future with such statements about those patients seen in further episodes of care.

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