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Sample patient's hospital record. Electronic medical record of the patient

MEDICAL CARD.

Basic requirements for issuing a medical card for an outpatient

Obtaining reliable information that fully reflects the state of health of patients, the availability of medical care, its quality and other issues of organizing outpatient care requires knowledge of the rules for maintaining primary medical records. Doctors do not always appreciate the significance of this problem and do not pay attention to the main accounting and operational medical, legal documents used in their work.

Medical documentation is documents of the established form, intended for registration of the results of medical, diagnostic, preventive, rehabilitation, sanitary and hygienic and other measures. It allows you to summarize and analyze this information. Medical documentation is accounting and reporting, its holders are medical institutions, therefore, doctors of medical institutions are responsible for the incorrect execution of the relevant documents.

Medical documents are the most important part of the treatment and diagnostic process, ensuring the interaction of medical workers and monitoring the health of patients in the provision of medical care to patients in outpatient settings. Only correctly executed primary medical documentation (including a medical record) allows medical personnel to make adequate decisions in specific clinical situations.

Accounting statistical medical documentation, on the basis of which morbidity and mortality statistics are formed, is quite complex, so misunderstanding or carelessness when filling it out can lead to serious errors. The data reflected in the medical record of an outpatient is important for the formation of reliable state statistical reporting.

Medical documentation drawn up in medical institutions is used in the implementation of departmental and non-departmental quality control of medical care. The increase in the number of pre-trial and trial proceedings, the need to further improve the system for monitoring the quality of medical care and evaluating the work of medical workers significantly increase the requirements for maintaining primary medical records. In addition, the attending physician must constantly remember the legal side of maintaining medical documents, observing the basic rules for filling them out.

Based on the foregoing, it should be emphasized the expediency of standardizing primary medical documentation, this will help the doctor develop the skills to complete it and save time.

The main primary accounting document of outpatient care is the outpatient medical card - form No. 025 / y-87, approved by order of the USSR Ministry of Health of December 31, 1987

No. 1338 "On maintaining new form outpatient medical record” (as amended and supplemented), and form No. 025 / y-04, approved by order of the Ministry of Health and Social Development of Russia dated November 22, 2004 No. 255 “On the procedure for providing primary health care to citizens entitled to receive a set social services". Account forms No. 025 / y-87 and No. 025 / y-04 are filled out in accordance with the instructions approved by the relevant orders (see attachments).

The outpatient medical record is the main medical document of a patient undergoing examination and treatment in an outpatient setting. It is filled in for each patient at the first request for medical care at a health facility. The medical card of an outpatient for citizens entitled to receive a set of social services is marked with the letter "L".

^ The main principles of maintaining an outpatient medical record are:

description of the patient's condition, treatment and diagnostic measures, treatment outcomes and other necessary information;
observance of the chronology of events influencing the adoption of clinical and organizational decisions;
reflection in medical records of social, physical, physiological and other factors that may affect the patient and the course of the pathological process;
understanding and compliance by the attending physician with the legal aspects of their activities, duties and significance of medical records;
recommendations to the patient at the end of the examination and the end of treatment.

Outpatient medical record. Design requirements:

fill in the title page of the medical record in accordance with the orders of the Ministry of Health of the USSR dated December 31, 1987 No. 1338 and the Ministry of Health and Social Development of Russia dated November 22, 2004 No. 225;
reflect the patient's complaints, the history of the disease, the results of an objective examination, the clinical (verified) diagnosis, the prescribed diagnostic and therapeutic measures, the necessary consultations, as well as all information on the observation of the patient at the prehospital stage (preventive medical examinations, the results of dispensary observation, appeals to the ambulance station assistance, etc.);
identify and fix risk factors that can aggravate the severity of the disease and affect its outcome;
present objective, substantiated information to ensure that medical personnel are “protected” from the possibility of a complaint or legal action;
fix the date of each entry;
each entry must be signed by a doctor (with full name decoding).
stipulate any changes, additions indicating the date of the changes and the signature of the doctor;
not allow records that are not related to the provision of medical care to this patient;
records in the outpatient card should be consistent, logical and thoughtful;
timely refer the patient to a meeting of the medical commission and medical and social examination;
pay special attention to records in the provision of emergency medical care and in complex diagnostic cases;
justify the prescribed treatment for the privileged category of patients;
provide for preferential categories of patients to issue prescriptions in 3 copies (one is pasted into the outpatient card). The outpatient medical record consists of long-term information sheets(pasted at the beginning of the map) and operational information sheets.

The sheets of long-term information reflect: the passport part, in the sheet of signal marks - blood type, Rh factor, allergic reactions, infectious diseases.

The long-term information sheet includes a sheet for recording final (refined) diagnoses. These records are essential for the completeness and accuracy of morbidity records. Timely recording of all diagnoses in the list of final diagnoses allows the doctor to easily and quickly obtain information about previous diseases suffered by the patient, which is important for assessing the state of his health. Entries in the list of final diagnoses also allow the attending physician to resolve issues of dispensary observation, special treatment, the need for counseling, etc.

Subsequently, the outpatient medical record is supplemented with sheets of operational information - in the order of current events. The attending physician in the primary medical documentation fixes the date, and in some cases the hour of contacting the health facility.

Taking into account the complaints of the applicant, their details, the history of the disease, and the data of the objective examination, the doctor establishes the nosological model of the patient (Order of the Ministry of Health of Russia dated 03.08.1999 No. The model takes into account the stage, phase of the disease and possible complications. When making a diagnosis, special attention should be paid to its validity.

All morbid conditions and health-related problems identified during the doctor's contact with the patient are subject to registration and coding. Nosology is coded according to the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10).

Particular attention should be paid to the appointment medicines benefit category of patients.

The outpatient medical record must contain:

doctor's record of admission, diagnosis, results of examination of the patient at the time of discharge of medicines, confirming the need for them;
date of issue of prescriptions;
copies of issued prescriptions indicating the number of the prescription;
dose and frequency of administration medicines.

The date of issue of the prescription, its number, the name of the medicines must correspond to the entry in the outpatient card. Prescribed medicines must comply with ICD-10 disease codes. The issuance of subsidized medicines to citizens who are not included in the Federal Register of Persons Eligible for State Social Assistance is prohibited.

When temporary disability an expert history is collected, an examination of temporary disability is carried out. When a patient is recognized as temporarily disabled, including when visiting a patient at home, a certificate of incapacity for work (certificate) is issued in accordance with the order of the Ministry of Health and Social Development of Russia dated 01.08.2007 No. 514 “On the procedure for issuing sheets of temporary disability by medical organizations” and other applicable normative documents. The series, the number of the disability certificate, the extension period, the date of the next visit to the doctor are indicated.

During subsequent examinations, the outpatient's medical record reflects the dynamics of the course of the disease; the effectiveness of the treatment; justifies either the extension of the patient's release from work (study), or the closure of the sick leave (certificate).

When referring a patient to a meeting of the medical commission, the doctor draws up a brief epicrisis indicating the purpose of the referral, with a mandatory assessment of the patient's condition in dynamics, analysis of the results of the examination and treatment. The number of days of temporary disability for the last case of temporary disability and for the last 12 months, the presence (or absence) of a disability group, the estimated labor and clinical prognosis (with justification) are also noted.

Recorded in medical records patient consent to medical intervention. This is provided for in Art. 32 (“Consent to medical intervention”) of the Fundamentals of Legislation Russian Federation on the protection of the health of citizens (hereinafter referred to as the Fundamentals), which states that "a necessary precondition for medical intervention is the informed voluntary consent of a citizen." This conclusion introduces 3 characteristics of medical intervention:

preliminary (the patient should have time to study the information and make a decision regarding the proposed option for examination and treatment);
awareness (includes information about the presence of the disease, treatment methods, associated risks, options medical interventions, their consequences and the results of the treatment. Information is provided to the patient in accordance with Part 1 of Art. 31 Fundamentals);
voluntariness (the patient himself must decide on medical intervention, while he can consult with other specialists).

“In cases where the condition of a citizen does not allow him to express his will, and medical intervention is urgent, the issue of its implementation in the interests of the citizen is decided by a council, and if it is impossible to convene a council, the attending (duty) doctor directly, followed by notification of officials of the healthcare facility” (Article .32 Fundamentals). In Art. 32 there is no concept of "legal" representative.

In the medical records, the patient's voluntary consent to medical intervention must be drawn up in accordance with clause 03.02.10 "Informed consent form of the patient when performing the protocol and additional information for the patient and family members" of the order of the Ministry of Health of Russia dated 03.08.1999 No. 303 "On the introduction of the operation of the industry standard “Protocols of patient management. General requirements"". The informed consent form for the implementation of the protocol is developed taking into account the characteristics of each patient model and should include the following: general information:

about etiology and pathogenesis;
methods of diagnostics, treatment, rehabilitation;
methods of primary and secondary prevention;
prospects and results of medical intervention;
possible complications, methods and results of their correction;
impact of medical intervention on quality of life.

“It is possible to create in one protocol several forms of informed consent of the patient, reflecting issues related to the diagnosis of the disease, individual methods of prevention, treatment and rehabilitation.

If the patient management protocol contains methods of prevention, diagnosis and treatment that are potentially dangerous for the life and health of the patient, the experts should separate them into a separate section of informed consent and provide information about possible complications, methods for their prevention and correction.

When developing an informed consent form, it is necessary to take into account the traditions that have developed in the country, the peculiarities of the mentality, national and religious restrictions.

additional information for the patient, they include information for self-treatment and information for family members on caring for the patient, the peculiarities of his diet, regimen, and medication” (Order of the Ministry of Health of Russia dated 03.08.1999 No. 303 “On the introduction of the industry standard “Protocols of patient management. General requirements” ").

Consent to medical intervention is issued in all cases of examination, treatment and other actions that have a preventive, diagnostic, therapeutic, rehabilitative, research orientation, performed by a doctor or other medical worker in relation to a particular patient. It must be signed by the attending physician and the patient.

In accordance with Art. 33 (“Refusal of Medical Intervention”) of the Fundamentals “... a citizen or his legal representative has the right refuse medical intervention or demand its termination... When refusing medical intervention, a citizen or his legal representative in a form accessible to him should be explained the possible consequences. Refusal of medical intervention indicating possible consequences documented in the medical records (including the corresponding medical record of the patient) and signed by the citizen or his legal representative, as well as a medical worker.

In the event of the death of a patient, simultaneously with the issuance of a death certificate, records of the date and cause of death are made in the medical record of the outpatient. The cause of death is the disease or injury that caused the chain of disease processes that led to death, or the circumstances of the accident or act of violence that caused the fatal injury. The medical records of the deceased are removed from the current file cabinet and transferred to the archive for storage.

Clause 3.2 of the Order of the Ministry of Health of Russia No. 291, FSS of Russia No. 167 dated 06.10.1998 "On approval of the Instruction on the procedure for monitoring the organization of examination of temporary disability" indicates that the heads of the health authorities of the constituent entities of the Russian Federation must ensure the storage of medical records of outpatients in health care facilities in in accordance with the established procedure. The order of storage and movement of medical records it is expedient to regulate an outpatient by the order of the chief physician of the health facility. The storage system for primary medical records should exclude violation of confidentiality and the possibility of illegal access to it.

Attachment 1

Instructions for maintaining a new form

outpatient medical record No. 025/u-871

The medical card of an outpatient is the main document reflecting the state of health of the patient, and is filled in for all those who applied to this medical institution for the first time.

The medical card is filled in in all institutions conducting outpatient reception, general and specialized, urban and rural, medical health centers.

Note:

1. The outpatient medical card is filled out:

- in anti-tuberculosis institutions - for initially applied and consultative patients; for contingents registered by an anti-tuberculosis institution, a medical card of a patient with tuberculosis is filled out (form No. 081 / y);

- in skin and venereal institutions - for patients with skin diseases and patients referred for consultation; for patients with venereal diseases, a card of a patient with venereal diseases (form No. 065 / y) is filled out, for patients with fungal diseases - a medical card for a patient with a fungal disease (form No. 065-1 / y);

- in women's consultations- for gynecological patients and women who applied for abortion; for pregnant women and puerperas, an individual card of a pregnant woman and a puerperal is filled out (f. No. 111 / y).

2. At feldsher-obstetric stations and health centers, instead of a medical card of an outpatient patient, a log of registration of outpatients (f. No. 074 / y) is kept.

With the simultaneous introduction of new medical records into the work of outpatient clinics, all medical registrars, district nurses and nurses of specialist doctors are involved in filling out its front side (passport data). The head nurse supervises all work, and senior nurses in therapeutic departments.

The outpatient medical record consists of forms for long-term information and forms for operational information. Long-term information forms include alarm marks, a final diagnosis record sheet, preventive examination data, and a drug prescription record sheet. They are pre-attached (in the printing house) to the hard cover of the medical record. Operational information forms include formalized inserts for recording the patient's first contact with the following specialists: a local therapist, cardiologist, rheumatologist, endocrinologist, surgeon, urologist, neuropathologist, otolaryngologist, ophthalmologist, as well as inserts for a patient with influenza, acute respiratory infections, tonsillitis, to record a consultation with the head. department, a milestone epicrisis at the VKK, an insert for a return visit. Forms of operational information are glued to the comb of the outpatient card in the completed form as the patient contacts the specialists at the outpatient appointment and at home.

^ Long-term information about the patient

The form "Signal marks" is filled in by a doctor of any specialty in the presence or detection of the signs listed in this sheet. The entered data is confirmed by the doctor's signature and seal.

The "Final (refined) diagnoses record sheet" is filled in by doctors of all specialties for each disease for which the patient applied to this institution in the reporting year. A disease detected in a patient for the first time in his life is considered to be diagnosed for the first time and is marked with a “+” (plus) sign. Moreover, if the disease is established when applying for the disease, then the “+” sign is affixed to the 3rd column; if the disease is detected during a medical examination, then the “+” sign is put in the 4th column. Diseases that can reappear several times (tonsillitis, influenza, acute respiratory infections, pneumonia, trauma, etc.) are considered newly diagnosed each time and are marked with a “+” (plus) sign. Chronic illness, with which the patient treated in previous years, in case of treatment in the reporting year, it is again entered in the list, but with a "-" (minus) sign.

1 Approved by the order of the Ministry of Health of the USSR of December 31, 1987 No. 1338 “On the introduction of a new form of an outpatient medical record” (as amended and supplemented).

In cases where the doctor cannot make an accurate diagnosis at the first visit of the patient, the estimated diagnosis is recorded on the page of current observations, only the date of the first visit is entered on the list for recording clarified diagnoses. The diagnosis is entered after its clarification.

In the case when the diagnosis made and recorded on the “sheet” is replaced by another, the incorrect diagnosis is crossed out and a new diagnosis is entered without changing the date of the first visit.

If a patient simultaneously or sequentially has several diseases that are etiologically unrelated to each other, then all of them are put on the “sheet”.

The form "Data of medical examinations" is filled out during the annual preventive examinations. It is designed for 5 years. The examination is carried out according to 15 signs (height, body weight, visual acuity, intraocular pressure, hearing acuity, pneumotachometry, arterial pressure, ECG, oral examination, blood test, urinalysis, fluorography, mammography, gynecological examination with smear, digital examination of the rectum). The results of the examination are entered in the column of the current year in the office where the corresponding examination or examination of the patient was carried out.

The record sheet for the prescription of narcotic drugs and drugs that can cause addiction includes all entries about all narcotic drugs and all other drugs that can cause addiction (their list is announced by the information letters of the Ministry of Health). USSR, Ministries of Health of the Union and Autonomous Republics, heads of regional and regional health departments).

Control over the validity of prescribing these medicines (clause 3.5 of the order of the USSR Ministry of Health of January 29, 1987 No. 149-DSP) is assigned to the chief doctors of medical institutions.

In all cases, all columns of the form must be clearly filled out and countersigned by the doctor.

^ Operative information

Inserts “Examination of a therapist”, “Inserts for a patient with influenza, acute respiratory infections, tonsillitis”, “Examination of a cardiologist”, “Examination of a rheumatologist”, “Examination of an endocrinologist” are filled out during the initial visit to therapeutic doctors. When examining a patient or conducting a medical examination, one should adhere to the plan that is available in the form. For each sign, the norm is underlined, and the pathology is entered in the appropriate column. When the patient re-applies, the "Re-examination" is filled out. When recording the results of a re-examination, only the dynamics of changes in the patient's condition, examination data, treatment and examination of working capacity are entered. All of these inserts are sequentially glued to the cover of the medical record as the patient contacts.

The insert "Stage epicrisis at the VKK" is filled in by the attending physician to resolve issues of examination of temporary disability. The reverse side of this insert is intended for the "Consultation of the head of the department", which makes recommendations on additional examination, diagnosis, treatment, rehabilitation therapy, examination of working capacity and employment.

Inserts "Examination of a surgeon", "Examination of an otolaryngologist", "Examination of an ophthalmologist", "Examination of a neuropathologist", "Examination of a urologist" are filled out during the initial visit to specialist doctors. They are filled in the same way as the inserts described for medical practitioners. Records of re-visit are carried out on additional forms "Re-examination".

The results of analyzes and examinations, the final epicrises of inpatient treatment are pasted into the medical record.

The insert "Census epicrisis from the medical record" is intended for entering information about the patient when establishing a new approved form of the outpatient medical record, as well as when registering the medical record for storage in the archive. It is supplemented by a list of updated diagnoses.

In case of hospitalization of a patient in a hospital united with a polyclinic, the card is transferred to the hospital and stored in the medical record of the inpatient. After the patient is discharged from the hospital or his death, the outpatient medical record with the epicrisis of the attending physician of the hospital is returned to the clinic. In the event of the death of a patient, simultaneously with the issuance of a medical certificate of death, a record is made in the card about the date and cause of death. The medical records of the deceased are removed from the current file cabinet and transferred to the archive of the medical institution.

Appendix 2

Filling instructions

registration form No. 025 / y-04 "Medical record of an outpatient"

(Approved by order of the Ministry of Health and Social Development of Russia dated November 22, 2004 No. 255 “On the procedure for providing primary health care to citizens entitled to receive a set of social services”)

The outpatient medical record (hereinafter referred to as the card) is the main primary medical document of a patient treated on an outpatient basis or at home, and is filled out for all patients when they first apply for medical care at this medical institution.

For each patient in the polyclinic, one medical record is maintained, regardless of whether he is being treated by one or more doctors.

Cards are maintained in all institutions conducting outpatient reception, general and specialized, urban and rural, including feldsher-obstetric stations (hereinafter referred to as FAPs), medical and feldsher health centers, medical cards are located in the registry on the basis of the district principle, Cards of citizens eligible to receive a set of social services are marked with the letter "L".

The title page of the Card is filled in at the reception desk of the medical institution when the patient first seeks medical assistance (consultation).

On the title page of the Card, the full name of the medical institution is affixed in accordance with the registration document and the PSRN code.

The Card number is entered – an individual card registration number established by the medical institution.

Line 1 "Insurance medical organization" indicates the name of the insurance company that issued the compulsory medical insurance policy.

In line 2, the number of the compulsory medical insurance policy is entered in accordance with the form of the submitted policy.

Line 3 contains the code of the benefit.

Line 4 contains the insurance number of an individual personal account (SNiLS) of a citizen in pension fund of the Russian Federation, which is formed in the Federal Register of persons entitled to state social assistance in the form of a set of social services (Federal Law of July 17, 1999 No. 178-FZ “On State Social Assistance”, Collection of Legislation of the Russian Federation of August 30, 2004 No. 35 , item 3607).

Surname, name, patronymic of a citizen, his gender, date of birth, address of permanent residence in the Russian Federation are filled in in accordance with an identity document.

If a citizen does not have a permanent place of residence in the Russian Federation, the address of registration at the place of stay is indicated.

Phone numbers, home and work, are recorded according to the patient.

In lines 13 "Document certifying the right to preferential support (name, number, series, date, issued by)" and 14 "Disability group" an entry is made according to the submitted document.

In line 14, the disability group that the patient has is entered.

In line 15, a note is made about the place of work, position. In the event of a change in address or place of work, point 16 is completed.

The table of clause 17 "Diseases subject to dispensary observation" indicates the diseases that are subject to dispensary observation in this medical institution, indicating the date of registration and deregistration, the position and signature of the doctor who carries out dispensary observation of the patient.

Entries in this table are made on the basis of the "Dispensary observation control card" (registration form No. 030 / y-04).

Line 18 is filled in in accordance with the results of laboratory tests. Line 19 is filled in according to the medical documentation about the identified drug intolerance or from the words of the patient.

In the event of the death of a patient, simultaneously with the issuance of a medical certificate of death, a record is made in the card about the date and cause of death.

The medical records of the deceased are removed from the current card file and transferred to the archive of the medical institution, where they are stored for 25 years.

A patient may be under observation for the same disease by several specialists (for example, for peptic ulcer, chronic cholecystitis by a therapist and surgeon), in the table of paragraph 17, such a disease is recorded once by the specialist who first took him under dispensary observation. If the patient is observed for several etiologically unrelated diseases by one or more specialists, then each of them is placed on the title page.

If the nature of the disease changes in the patient (for example, ischemic heart disease joins hypertension), then a new diagnosis is entered in the table on the title page without the date of registration, and the old entry is crossed out.

Particular attention should be paid to the entries on the sheet of final (refined) diagnoses, where doctors of all specialties enter the diagnoses established at the first visit to the clinic and home care in a given calendar year, regardless of when the diagnosis was made: at the first or subsequent visits or in previous years.

In cases where the doctor cannot make an accurate diagnosis at the first visit to the patient, the estimated diagnosis is recorded on the page of current observations, only the date of the first visit is entered on the list for recording clarified diagnoses. The diagnosis is entered after its clarification.

In the case when the diagnosis made and written down on the “sheet” is replaced by another, the “incorrect” diagnosis is crossed out and a new diagnosis is entered without changing the date of the first visit.

If a patient simultaneously or sequentially has several diseases that are etiologically unrelated to each other, then all of them are put on the “sheet”. In the case of the transition of the disease from one stage to another (with hypertension, etc.), the recorded diagnosis is repeated again with an indication of the new stage.

If during the treatment of the patient a disease is detected, about which the patient has not previously applied to any medical institution, then such a disease is considered to be detected for the first time and is marked on the “sheet” with a “+” (plus) sign.

Diseases that can occur in one person again several times (tonsillitis, acute inflammation upper respiratory tract, abscesses, injuries, etc.), each time a new occurrence is considered for the first time identified and marked on the “sheet” with a “+” (plus) sign.

All other entries in the medical record are made by the attending physicians in the prescribed manner, in the order of current observations.

The medical record also contains records of the results of consultations of specialists, medical commissions, etc. Outpatient medical records, the history of the development of the child are stored in the registry: in polyclinics - by sites and within the sites by streets, houses, apartments; in central district hospitals and rural outpatient clinics - by settlements and alphabetically.

^ Notes

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^ Notes

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Each person probably had to visit medical institutions, where one of the most important documents is the medical record of an outpatient. Neither the doctor nor the patient can do without it.

Why do I need an outpatient card?

The fate of the patient within the framework of a possibly investigated criminal or civil case may depend on how correctly this document is filled out.

An extract from the outpatient card is required:
⦁ in the implementation of forensic examinations;
⦁ to make payments for the provision of medical care under compulsory medical insurance contracts;
⦁ to conduct medical and economic examinations to control the quality of medical services performed.

What is an outpatient patient card?

In the Federal Law No. 323, approved in November 2011, which regulates the protection of the health of our compatriots, there is no such thing as medical documentation.

The Medical Encyclopedia refers to it a system of documents that have an established form, the purpose of which is to register information about measures for prevention, treatment, diagnosis and sanitary hygiene.

Medical documentation can be accounting, reporting and accounting. The outpatient medical record belongs to the first category. It describes the diagnoses, the current condition of the patient, recommendations for treatment.

Introduction of the updated form

Order of the Russian Ministry of Health No. 834 of December 2014 approved updated unified forms of documentation in circulation in outpatient medical institutions. It also states how they are filled.

This is a significant step towards the creation of an electronic medical record, since the introduction of uniform standards in the execution of records ensures mutual continuity among medical institutions.

In particular, form No. 025 / y - "Medical record of an outpatient" has been developed, and it is described in detail how it should be filled out. In addition, a sample of the patient's coupon with the appropriate filling procedure has been approved.

By the above order, this card was given the status of the main accounting medical document of an institution providing medical care for the adult population using outpatient conditions.

What is the difference from the old form?

In the new accounting form, the information content is significantly increased, the positions filled in are specified in more detail. In the previous version, the doctor could make notes at his own discretion, now they are unified.

Be sure to enter the following information:
⦁ about consultations of narrow medical specialists and the head of the department;
⦁ on the outcome of the CWC meeting;
⦁ about taking x-rays;
⦁ on the diagnosis of the 10th International Qualification of Diseases.

Each specialized medical institution or their specialized structural area in dentistry, oncology, dermatology, psychology, orthodontics, psychiatry and narcology has its own outpatient card. Form No. 043-1 / y, for example, is filled out for orthodontic patients, No. 030 / y is intended for a control card for dispensary observation.

Form No. 030-1 / y-02 is issued to persons suffering from psychiatric diseases and drug addiction. It was approved in the Order of the Ministry of Health of the Russian Federation of 2002 No. 420.

How is it filled?

During the very first visit of a person to the clinic, the registry fills in the data on the title page. But the outpatient card of the patient can only be filled out by doctors.

If the patient belongs to the category of federal beneficiaries, "L" is affixed next to the card number. The doctor must make an appropriate record of each visit to the clinic by the patient.

Outpatient card reflects:
⦁ how the disease proceeds;
⦁ what diagnostic and therapeutic measures are consistently carried out by the attending physician.

The recording is done neatly, in Russian, in the appropriate section without any abbreviations. If it is necessary to correct something, this is done immediately after the mistake is made and must be certified by a medical signature.
It is permissible to use Latin to write the names of medicines.

The health worker fills out the first sheet in the registry according to the data from the patient's identity documents. The graphs of the workplace and positions are recorded according to the patient. The form contains instructions for completing each section.

Filling principles

When filling out an outpatient card, there are some basic principles to keep in mind.

It should describe in chronological order:
⦁ in what condition did the patient come to see the doctor;
⦁ what diagnostic and treatment procedures were performed;
⦁ results of treatment;
⦁ circumstances of a physical, social and other nature that affect the patient during pathological changes in his state of health;
⦁ the nature of the recommendations to the patient issued at the end of the examination and the treatment process.

The doctor must comply with all legal aspects when completing the form.

The outpatient card consists of forms on which long-term and operational information is recorded.

The permanent information contained on the front adhesive sheets includes:
⦁ information copied from an identity document;
⦁ blood type with Rh factor;
⦁ information about past infectious diseases and allergic reactions;
⦁ final diagnoses;
⦁ results of preventive examinations;
⦁ a list of prescribed narcotic drugs.

Operational information is entered on the inserts, where the results of the initial treatment and secondary visits of the local therapist, narrow-profile doctors, and consultations with the head of the department are recorded.

Extract from the outpatient card

An extract is a medical certificate on the state of health in the form 027 / y, which belongs to the second group of medical records documentation. It contains information about previous diseases during outpatient treatment.

Its purpose, as well as the entire documentation of this group, is the implementation of an operational exchange of data on the health of patients, which helps to connect the individual stages of sanitary and preventive and therapeutic measures.

An extract may be provided by the patient to the employer to inform about outpatient treatment. It is not subject to payment, but is rented together with a sick leave, if the latter is issued for more than a month.

This document allows you to exempt from classes in educational institutions.

The extract contains information about the patient, indicating the medical policy number, listing his complaints, symptoms of the disease, the results of medical examinations and examinations, as well as the primary diagnosis.

All information must fully comply with that contained in the outpatient card.

The extract can be used to prescribe further medical procedures.

Fact 1. A paper duplicate is still needed

The standard for maintaining an electronic card is enshrined in GOST R 52 636–2006, and records corresponding to this GOST have the status of an outpatient card. But, since the order to maintain a paper outpatient card is still in effect, it is not yet possible to confine ourselves to the electronic version only. Most often, the information is duplicated in ordinary paper cards, which makes it possible to transfer data to other health facilities that are not yet equipped with a computer system or maintain electronic cards using a different program. The simplest option is to periodically print out data from the information system and enter it into a paper map.

Fact 2. Multi-availability

The database of the clinic is structured as follows: a local area network with centralized control, similar to the Internet, is created in the medical facility, protected in accordance with the requirements of the law on the preservation of medical secrets. There is a central server where all patient information is stored, divided into individual folders. From computers at workplaces, you can view or change the contents of any folder at any time, according to the access level. Thus, the “page” of the patient can be simultaneously filled in by different departments and specialists, for example, an oculist, a radiologist and a laboratory doctor who enters the results of analyzes into the map. The card does not need to be shifted from place to place, it is not necessary to hand it over to the patient every time and track its return.

Fact 3. EHR simplifies many processes

With an electronic card, the anamnesis of life is always at hand, it is available in a special tab or via a quick link. This will definitely simplify and speed up work with elderly patients with mnestic disorders. Also on the patient's page you can see a list of updated diagnoses, a list of appointments and consultations, an allergic anamnesis, data on the carriage of infections. Without digging into a paper map, without deciphering the handwriting of colleagues, without looking in leaflets wrapped in half, you can quickly get acquainted with the results of examinations. You can record your appointment by filling out a special form, which is customized individually. You can attach a drawing or photo, the results of the manipulations, to the inspection. It simplifies the computer and the issuance of appointments and referrals (the part of the appointment containing recommendations is automatically printed out), as well as filling out coupons and encrypting the diagnosis according to the ICD.

Hippocrates did not even dream of medical records, histories of diseases and childbirth, and even more so electronic versions of these documents! Read on to learn how the digital future is invading hospitals and clinics.

An electronic medical record, or an electronic medical record (EMC), is electronic document, designed to maintain medical records, search and issue information upon request (including via electronic communication channels).

The task of the EGISZ is to promptly receive information on the volume of medical care provided to the population, so that it would be easier for the state to plan the costs of medicine and optimize the expenditure of budgetary funds. In the future, the Uniform State Health Information System will become very convenient for practicing doctors. If it is possible to establish its work, consultations, hospitalizations, transfers will be processed easier

Fact 4. EHR enhances control

The use of electronic cards makes the work of a medical organization more transparent in every sense. At any time, each entry can be checked by the management, insurance company, supervisory authorities. Competent and timely internal control allows you to get closer to flawless record keeping, which will help you avoid penalties during external audits.

Fact 5. The patient will be denied access

With a full transition to electronic documentation, patients will not have direct access to their outpatient card. The patient will not be able to take the card home for their own personal reasons or remove the results of studies or analyzes from it, which is convenient for the clinic, which in this case does not face fines if this card is requested for verification. The information system, if necessary, allows you to simply and quickly print out an extract for the patient. There are projects of more technological solutions, for example, a special memory card on the hands of the patient, duplicating the outpatient card.

Fact 6. EHR will be implemented everywhere

The creation of a unified medical information system is a state initiative, which is recorded in the order dated April 28, 2011 No. 364 “On approval of the concept of creating a Unified State Health Information System” (EGISZ). So sooner or later computerization will be introduced everywhere.

Fact 7. Grandiose plans

The federal-level services planned in the unified information system, for example, an integrated information medical record, imply a much higher level of storage and transmission of medical information than it is now. For example, if doctors in an ambulance or an emergency hospital have the opportunity to familiarize themselves with a patient's outpatient record, this can save many lives.

What do you think?

I really like the electronic card, despite the fact that the transition to it was difficult. It is not possible to implement all the functions at once, but we are moving towards this. Now we already manage not only cards, but also records of doctors' working hours, payroll, warehouse. There are many problems with the training of experienced specialists who come from ordinary clinics and did not work on a computer. They are afraid. And young people immediately take it and work, they, of course, also have shortcomings, but we work, we check, it’s still easier than with paper.
Deputy chief physician for clinical and expert work, polyclinic in the Moscow region

In general, in institutions that maintain an electronic medical history or an outpatient card, the level of documentation is much higher. Apparently, this is due to the fact that someone from the administration of the clinic seriously checks the primary documentation.
Tatyana, doctor-expert of the insurance company

Still, there is no sense of reliability from an electronic card. We got used to the cards for many years, picked up the card - - began to receive. And in the computer you press something wrong, and it will take it and delete it, or someone else will edit the map - then look for the ends. And the patients are uncomfortable. You can write a card almost without looking, but questioning the patient and looking at the computer is somehow impolite. Again, if the patient has already left, then the next one will immediately enter, the paper card can be put aside and returned to it later, but with an electronic one it is more difficult. By the end of the day, everything is already mixed up, you can’t collect it. Life does not stand still, maybe later we will not be able to do without a computer. With analyzes, it’s already convenient - everything is with numbers, printed, directions are drawn up by themselves.
Olga, therapist of the highest category, work experience 16 years

An electronic map isn't perfect, but it's better than a scribble. Checking the boxes, instead of writing the same thing a hundred times, still saves a lot of time. But while you have to print out the reception, sign it and glue it on the card - it doesn't make much sense. At the same time, if the patient came, for example, only for washing, you still have to make out as an appointment, so that the insurance pays, and this is not very convenient. But in principle, filling out a map is no more difficult than filling out a page on a social network, so there are no problems with the database.
Larisa, ENT doctor of the first category, work experience 11 years

Electronic medical records, as conceived by experts, should replace paper ones, which from time immemorial doctors and nurses filled out and now fill out on their own. Now information systems have been introduced that allow you to see the medical electronic card of any patient in any city that is already covered by this system. But this is available only to those specialists who are endowed with access to this unified information system by their position. Still, no one canceled the medical secret, it is preserved.

If a person has a password, he can look at the cards entered into this system.

And if he doesn’t, then only through his attending physician can he try to see her.

I think that the electronic medical record can be shown by the attending physician or by order of the head physician of the hospital upon presentation of a passport. But while people still know little about such subtleties in medicine, they use handwritten medical records if necessary.

Medical electronic cards have been introduced in Russia since 2013. Several software products have already been developed - information systems, such as, for example, Samson or Medialogquot ;. They are now undergoing a run-in in different regions; in order to choose the best one and make it uniform throughout Russia.

Electronic medical records are one of the modules of these information systems. They are analogues of case histories, which now, in most cases, doctors still write by hand. Here you can read what an electronic medical record is. I am somehow not sure that such documentation can be available to patients. Still, a handwritten case history is not allowed to be handed over to patients; they are carried from office to office by a nurse or an orderly, but not by the patient himself. There is also the concept of medical secrecy, which the doctor is obliged to keep. As for the electronic medical record, I don't think patients will be allowed access.

The map page looks like this:

Even this picture shows that a simple patient here may be of little interest. Everything is presented in a professional language with special terms.

Although on another site, here, there is an indication of Patient's personal account, as a separate online service:

Perhaps, through his Personal Account, by registering, he will be able to receive some information about the results of tests, diagnosis, procedures, etc. But for this it is necessary that the service becomes available to the public.

Electronic medical records are designed so that the doctor of any hospital or clinic has access to the patient's medical history. They began to implement them back in 2013 and in 2014 they promised to completely switch to them.

But, unfortunately, even today, in 2016, not all regions work with EHR.

To ensure the privacy of the data stored on the card, it is password protected. Doctors have access to the password. It should also be possible to access the map via Personal Area Patient. But, unfortunately, today it is practically not implemented. Therefore, the most acceptable option now is to ask the doctor to reset the information on the card to an electronic medium (flash drive).

If there is a need to view your electronic medical record (EMC), then you can contact your district or attending physician and he will dump its contents onto your flash drive, and possibly show the pages you are interested in on the monitor of your working computer. For example this one:

In order to view your electronic medical card, you need to contact the local doctor at the place of residence, since the information is only in his computer and it is not posted on a social network.

Electronic medical records were introduced in Russia not yesterday. However, this system does not yet cover all settlements, of course. I am almost sure that a resident of a small remote village will not be able to view his electronic map if he so desires. The technical capabilities are not enough.

As for larger places, you need to know:

Our electronic card, if it is already in place, is not in the public domain of the entire curious public. Medical secrecy and it will remain, and will remain. On the Internet, you do not need to type your name, this, fortunately, will not give anything.
But if you want to see all the correspondence between your condition, the services received and what is written in the card, you need to go to the clinic to which we are attached. And there to talk with the district and the attending physician. He will tell you at what stage the development of the map is. And, probably, will show e pages on the monitor screen.

If there is such a need, then you need to take a coupon for an appointment with a local therapist and already at the reception voice your desire to see, you can go to the head nurse (you will get to her faster than to the doctor) with such a request - they will not refuse. But in the electronic map it will be the same, the same data as in the paper map.
The electronic card is not a document that the patient can see in the public domain until the electronic system is adjusted. Not all doctors still have computers in their offices, there are no terminals for an electronic policy, and doctors protect diseases from the patient himself. They don’t give an ordinary card in hand, and they won’t give an electronic one now, all the more so. Until they decide how to encrypt data that the patient does not need to see.
And the most interesting thing is that the patient must collect the data for the electronic card himself. That is, it will no longer be the card that is stored in the clinic.
That is, doctors on their computers see all the illnesses of the patient, how he was ill, where he was treated. And the patient can only see the names of diseases.
Doctors are against patients seeing gray kitchen the work of doctors and doctors is against frightening the patient with terrible names of diseases.
But you can try to see the therapist in the office if he agrees to print your medical history for you.
To be honest, I didn’t even know that there is such a new opportunity to view your electronic medical record. It turns out that the attending physician does not have the right to refuse you, and at your first request, he must, without any questions, transfer the information about you about your state of health to you on your USB flash drive or portable hard drive.
My relative works in one of the hospitals as a programmer. It was he who began to introduce, as Tew correctly writes, this information program Samsonquot ;. I asked him everything.) This is such a special program throughout Russia. Doctors enter all information about patients into a computer into this program. And in Moscow, for example, they can come in and immediately read everything and give advice or comments. He also says that all the same, doctors keep medical records by hand, because there is more trust. None of the patients are shown electronic medical records, and the patients do not ask about these cards because they do not know about them).

What is an outpatient card? You will learn the answer to this question from this article. In addition, your attention will be provided with information about why such a document is being created, what items it includes, etc.

General information

The outpatient card is a medical document. In it, the attending physicians keep records of the prescribed therapy and the medical history of their patient. It should be noted that such a card is one of the main documents of a patient who is undergoing treatment and examination on an outpatient and outpatient basis. The form of the medical card is the same for everyone. Such a document is entered for each patient at his first visit to the hospital.

Medical record and its role in practice

The outpatient card primarily serves as the basis for any legal action (if any). Moreover, the correct filling of the patient's medical history is of great educational importance for the doctor, as it strengthens his sense of responsibility. It should also be noted that this document is very often used in insurance cases (in case of loss of health of the insured person).

Incorrectly filled cards

If the outpatient's medical record was filled out inaccurately or was lost by the registry, then patients can present reasonable claims to the institution. By the way, in some clinics there is such a practice as intentional loss. As a rule, this happens with poor clinical outcomes, errors in prescribing drugs and procedures, etc.

One of the means to improve the safety of outpatient cards is the introduction of their electronic versions. But this method has two sides: thanks to such documents, it is quite easy to track the sequence of their changes, however, the issued electronic card has no legal force.

The outpatient medical record includes forms for operational and long-term information. Let's consider their content in more detail.

Operational information forms consist of formalized inserts for recording the patient's first visit to the doctor, as well as for patients with influenza, tonsillitis and acute respiratory disease. In addition, they contain inserts for a return visit, for the consultation committee. Such forms are filled in as the patient contacts the doctor at home or at an outpatient appointment, and are glued to the spine of the card.
Forms of long-term information contain signal marks, information about preventive examinations, sheets for recording already specified diagnoses and sheets for prescribing any narcotic drugs. These inserts are usually attached to the cover of the card.

Basic principles of card management

An outpatient card is required for:

description of the patient's condition, outcomes of therapy, treatment and diagnostic measures and other information;
adherence to the chronology of events that influence the adoption of organizational and clinical decisions;
reflections of physical, social, physiological and other factors influencing the patient during the entire pathological process;
understanding and compliance by the attending doctor with all the legal nuances of their activities, as well as the significance of medical documentation;
recommendations to the patient after completion of the examination and completion of treatment.

Card issuance requirements

The outpatient card must be filled out by a doctor strictly according to the rules. He must:

Each entry is signed only by the attending doctor with a transcript of his full name. Recordings that have nothing to do with the care of this patient are not allowed. All marks in the medical record must be thoughtful, logical and consistent. Particular attention is paid to those records that were kept in complex diagnostic cases, as well as in the provision of emergency care.