A sample of a child's medical record. Title page of the child's honey card

Forms of certificates can be very diverse and depend on which particular team the person is to be in. In our country, a whole system of documents has been developed for these purposes.

In this article, we will study the issue of issuing and obtaining a certificate, without which a child cannot be admitted to Kindergarten. Attending preschool educational institutions is an important step in the life of both children and their parents. Therefore, you need to know exactly what is needed in order for the baby to start going to the garden. We will talk about the child's medical record form 026 / y, since parents are interested in what information it should contain and how it is issued.

The child enters kindergarten and school on the basis of the Order of the Ministry of Health of the Russian Federation. It is recommended to collect medical documents 1-2 months before the date of the first visit to a general education institution.

Consider the medical documents required for placement in a school or kindergarten. These include:

Card of preventive vaccinations F-63;

Medical card F-026u;

Vaccination certificate (blue book);

Information about the epidemiological environment.

What is a medical card for?

Form 026 / y is required for the child to be accepted into the team of a kindergarten or general education institution. Carrying out the examination provided for obtaining the card is important point not only to avoid the outbreak of epidemics in the group of preschoolers, but also to control the health of children. That is, in fact, it is a preventive measure. It must be remembered that a timely detected pathology gives a high chance of its complete elimination without consequences. What else does a child's medical card give?

If health problems are identified

In addition, if a child’s health problem is diagnosed during the examination, he or she can be sent to a specialized preschool institution, and parents will receive special recommendations about further action. If vision problems are found, then parents are advised to consider the option of a special kindergarten for children with similar pathologies. Such recommendations are not something terrible, on the contrary, they are aimed at ensuring that the child is provided with specialized assistance in restoring vision. Such kindergartens direct their activities to improve the health of children with visual pathologies.

If a student has pathologies that do not allow high-intensity physical activity, the pediatrician can prescribe special permission for not attending physical education classes at school. It can be either temporary, until the problem is fixed, or permanent.

Visiting specialists

The main question for all parents is which specific specialists need to be visited to obtain a certificate. The child's medical record involves consultations with a wide range of doctors. For its registration, first of all, you should visit a pediatrician. He will issue the necessary referrals to specialists, including for tests.

List of doctors

As a standard, the list of required specialists includes:

If the child suffers from any diseases in a chronic form, then, at the discretion of the pediatrician, referrals to other narrow specialists, such as a speech therapist, gynecologist, psychologist, endocrinologist or andrologist, may be issued. The Ministry of Health recommends going to a gynecologist for girls and an andrologist for boys from the age of 14. This is necessary even without indications, for the prevention of sexually transmitted diseases and pathologies in the reproductive system. It should be borne in mind that these specialists are not included in the mandatory visit list, and an examination can only be carried out in the presence of the child's parent.

Testing

In addition to visiting and consulting narrow specialists, in order to obtain a child's medical card, it is necessary to pass a series of tests. As a rule, these are standard studies:

1. Blood and urine for general analysis.
2. Feces on eggs of worms and other protozoa.

As a rule, the results of the research are provided a few days after the date of delivery. It depends on the workload of the outpatient laboratory. After receiving all the test sheets, a second visit to the pediatrician is required to issue a card. After that, it must be signed by the head physician of the clinic. The document is provided to the kindergarten at the request of the administration of the preschool institution. An example of a child's medical record is provided below.

It is considered optimal to give it a month before the expected start of the child's visit to kindergarten. A certificate to school is given before September 1, otherwise the child may not be allowed to attend classes. Thus, it is necessary to take into account the time for issuing a card in order to provide it in a timely manner at the place of demand.

The child's medical record 026 / y is signed by the head physician of the medical institution only if all the tests have been passed.

How to prepare for analysis?

In order not to have to repeat the analyzes due to the unreliability of the data, it is important to follow certain recommendations when preparing for them. These standard tips include:

1. Urine must be collected in special sterile disposable containers. Before the fence, you need to carry out hygiene of the genital organs and blot them with a towel, and then collect the middle morning portion.
2. Blood sampling should take place in the morning on an empty stomach. The analysis is carried out by piercing the finger with a special scarifier. Some parents prefer to purchase this needle on their own in a pharmacy.
3. Feces are also collected in plastic disposable containers, which are sold in every pharmacy.

Documents for registration

When the passage of the commission for issuing a child's medical card for kindergarten form 026 / y takes place at the clinic at the place of residence, only the child's policy is required. Specialists will be able to find all the necessary information in the child's development card stored in the clinic, including birth data and a vaccination card. If the choice fell on private clinic, then you will need to provide a package of documents, including:

1. Parent's passport.
2. Child's birth certificate.
3. An extract from the card in the clinic listing the vaccinations made.
4. A map of the history of the development of the child or an extract made by the local pediatrician.

Data on the map

The form of the child's medical record for the garden is filled out by a nurse or pediatrician. The following data is indicated on the front side of the document:

1. Surname, name, patronymic of the child.
2. Date of Birth.
3. Place of permanent or temporary registration.
4. Parents' data, including full name, place of work and phone number.
5. Vaccinations and reactions to them.
6. Allergy (if any).

Each narrow specialist fills out his own column in the medical record after examination and consultation. When all indicators are normal, a “healthy” mark is placed in a special column. If there are pathologies, the specialist enters data about them into the map and makes a decision on whether the child can attend the kindergarten on general terms.

How much does it cost to issue a child's medical card for kindergarten?

Inspection options and cost

A medical commission is carried out free of charge in the children's clinic at the place of residence. This process is quite lengthy, sometimes it takes more than a week, which is due to the discrepancy between the schedule of district specialists. It also takes quite a lot of time in state clinics to conduct tests. This is due to the poor equipment of laboratories in the clinic and their abnormal workload.

There are cases when schoolchildren are offered the option of passing a medical commission directly at an educational institution. It's also free and obviously convenient for both the child and the parents.

It is possible to issue a child's medical card on a private basis in a non-state clinic. The main advantage of this option is speed. Subject to prior appointment with specialists, required document can be received the next day after applying. With this option, it is possible to pass specialists even within one hour. However, you will have to pay a lot for such a high speed of service, since the cost will include both expert advice and laboratory tests.

The average cost of a medical examination is from three thousand rubles. It all depends on the chosen clinic. Private medical institutions offer a comprehensive examination for a certain amount. However, before using such offers, carefully study which specific specialists and examinations are included in the price so that you do not have to pay extra for the necessary consultation in the future. The purpose of passing a medical examination is not only and not so much in the design of a card, but also in the prevention of diseases and pathologies.

We have reviewed the child's medical record form 026/y.

COMPLETING THE TITLE SHEET OF THE MEDICAL CARD OF THE IN-SITE PATIENT

OKUD form code _______________

Institution code according to OKPO _________

Ministry of Health Medical records

Form No. 003 U

The name of the institution is approved by the Ministry of Health of the USSR

___________________________№ 1030

Date and time of admission

Date and time of checkout _____________________________

Department ____________________ ward No. _______

Transferred to the department _______________________________________________

Bed-days spent _______________________________________________

Types of transportation: on a wheelchair, on a chair, can walk (underline)

Blood type ____________ Rh affiliation _____________________

Side effects of drugs (intolerance)

1. Surname, name, patronymic: _____________________________________________

2. Gender: ____________

3. Age: ____ (full years, for children: up to 1 year - months, up to 1 month - days)

4. Permanent place of residence: city, village(emphasize)

5. Place of work, profession or position _______________________________________________

place of study for students; for children - the name of the children's institution, school; for disabled people, type and group of disability, JOB - yes, no (underline)

6. Who referred the patient: __________________________________

7. Delivered to the hospital for emergency indications: yes, no - ________ hours after the onset of the disease, injuries received, hospitalized in a planned manner (underline)

8. Diagnosis of the referring institution: _____________________________________________

9. Diagnosis at admission _________________________

10. Clinical diagnosis ______________________ Date of establishment __________________

11. Final clinical diagnosis

a) main ________________________________________________________________

b) complication of the main ___________________________________________________

c) concomitant ________________________________________________________________

Purpose: to ensure continuity in the actions of health workers.

Note: by the time the duty is handed over, all manipulations assigned to patients must be performed by the nurse handing over the shift.

Action algorithm

I. The nurses receiving and handing over the duty, together with the head nurse of the department, must:

1) make a round of all the wards with a report on patients in serious condition;

2) inspect the sanitary condition of the ward, ask the opinion of patients about the past duty (if there are any complaints or suggestions);

3) accept medical documentation:

a) a journal of medical appointments;

b) log of acceptance and delivery of duty;

c) registers of medicines of list A and B, together with the keys to the safe in which they are stored;

4) transfer medical instruments: thermometers, blood pressure monitors, syringes, etc.;

5) retake medicines that are at the post;

6) both nurses are present at the medical conference; the nurse handing over the shift reports on the dynamics of the state of patients, on the past duty, reports a summary of the movement of patients per day;

7) the nurse on duty fills out in the morning the "Sheet for the movement of patients and the hospital bed fund" and the "Portion requirement" in two copies - for the catering unit and the distributor

DEVELOPING A PORTION REQUIREMENT

Goal: Patients comply with the diet prescribed by the doctor.

Portion requirement forms f No. 1-84.

for the nutrition of patients in the therapeutic department at ________________________________

(date, day, month, year)

Information about the presence of patients as of 10:00

(day month Year)

1. Select numbers of therapeutic diets for each patient from the prescription sheets.
2. Enter them in the general list of patients at the post.
3. Submit to the head nurse by 9 o'clock the number of patients excluding those who are discharged today, as well as the number of meals for each treatment table and additional meals prescribed.

1. Indicate the name of the department, the number of patients at 10 o'clock, the date in the portioner.
2. Enter in the portioner the number of people eating at each table and information about the assigned additional meals. Sign a portion requirement with the head of the medical department.
3. Transfer the portion requirement to the diet service and canteen.

A child's medical record is created for each child attending school or kindergarten. The form of the child's medical record is usually standard. Let's look at what the sections of this map consist of.

Child's medical record 026 y

The child's medical card is used in educational institutions, it is issued for each minor child studying in kindergartens, general education and other schools, and similar organizations.

You can keep medical records of young patients online using the Clinic Online service. Try it and see how convenient it is.

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The child's medical record 026 U contains detailed data on the degree of moral and physical development of the child, whether he has health problems, and so on. The form of a standard medical record of a student (pupil) also allows you to record information about classifying a minor to a certain disability group by type of health, etc.

The child's medical record is usually filled in by a kindergarten, school health worker - or doctors, nurses or clinic paramedics.

You can download a sample of a child's medical record below.

The structure of the child's medical record form

The medical record is divided into several parts, in which various data about the minor are entered:

• General information about the student (pupil)
• Juvenile History Information
• Data on whether the student (pupil) is registered with the dispensary.
• Information about the timing and actual passage of mandatory medical procedures
• Information about the timing and actual passage of immunization
• Data on the timing and actual passage of medical examinations required by the age of the minor
• Results of consultations of medical specialists
• Recommendations for attending classes and their nature in various sports and other sections
• Data on the preparation of boys for military service
• Actual results of analyzes and medical observations of the student (pupil)
• Data of analyzes and medical conclusions.

How to fill out a child health record form

According to the regulations, the form of the child's medical record must be filled out by a health worker in accordance with the requirements for its design.

What is written in the "General information" section

1.General information about the child.

1.1. Surname, name, patronymic of the child _____________ 1.2. Date of Birth___________

1.3. Gender (M/F) 1.4. House. address (or residential institution address)__________________

1.5. tel. m/live. _____________ 1.6. Serving polyclinic __________________ 1.7. phone ___________________

The "General Information" section contains all information about the student (pupil), as well as the medical institution to which he belongs, taking into account the place of residence. The section includes the following information:

• details of the name and address of the minor;
• information about the clinic in which he is served;
• information about which school or kindergarten he attends.
• information about the transfer to any other educational institution, if any;
• in a special column all those negative conditions are reported in which a minor is forced to be daily for some reason.

The child's medical record 026 U also reports whether the minor has any allergic reaction, indicating the causes of the allergy.

Contents of the section “Anamnestic information”

Information about the history of minors is the next section of the medical record 026 U. It contains general data and characteristics of the family of a school student or kindergarten pupil. In addition, it contains information about the living conditions of the child, describes the diseases that he suffered. Externally, the section looks like this:

The most significant points in this section of the child's medical record:

• Information about the family of the student (pupil)
• This section includes information about the composition of the family of a minor, and about the general situation in it.
• Information about whether the student (pupil) and his family members have chronic or hereditary diseases
• The special paragraph of the section includes additional data on whether the student (pupil) participates in sections or hobby groups that the student (pupil) attends.
• Data on diseases suffered by the student (pupil), about various injuries or about those operations that the student (pupil) endured, this also includes information about being in a children's sanatorium-resort complex.

The health worker of the school or boarding school enters information about all this, based on the data of a regular outpatient medical card, and based on the results of a personal conversation with his parents and information received from teachers of the school or boarding school.

Information about being under the supervision of a doctor of a student (pupil) for whom a medical card is issued

The next section of the child's medical record directly relates to children who need to be monitored by a doctor in a clinic in their place of residence.

Externally, the section of the child's medical record form looks like this:

The purpose of completing this section is to control the implementation of various dispensary procedures. The health worker of the school or boarding school moves them to the child's card from the medical card of the polyclinic. It is extremely important to fill in all the columns of this block with data. And if a student (pupil) is removed from dispensary medical observation, the date and reasons for removing the student (pupil) from the register must be entered in this section of the child’s medical record form.

How to fill out the section on treatment and preventive measures

The fourth section includes data on the implementation of mandatory medical and diagnostic measures, for example, on the dates, terms and results of deworming or on the sanitation of the oral cavity of underage students (pupils).

Externally, the section looks like this:

Mandatory therapeutic and preventive measures

4.1 Deworming

4.2. Sanitation of the oral cavity

In the Russian Federation, in each institution, when observing a school student or kindergarten pupil, medical specialists are guided by the legislative acts of the Ministry of Health of the Russian Federation when working:

• Etc. No 60 dated 14.03.95
• Etc. No 186/272 dated 06/30/92
• Etc. No 151 of 07.05.98

These legislative acts regulate the frequency of passing medical examinations and other mandatory medical measures for underage students and pupils. In the described section of the child's medical record form, notes are recorded on the passage of these procedures with the addition of specific dates and types of events.

How to fill out the Immunization section of your child's health record form

This section includes data from doctors about what and when vaccinations were given to a minor who was not observed by health workers. The section contains the dates and dates of immunization activities, regardless of the cases for which vaccinations were made.

Section appearance:

Immunoprophylactic measures

5.1. Examination of a school student or kindergarten pupil before preventive and other vaccinations

In column (5.1.), the health worker indicates what diagnosis the student (pupil) had at the time of the vaccination. If the presence of this disease clearly conflicts with the possibility of immunization, or is a direct contraindication for it, the medical record of a school student or kindergarten pupil indicates the date until which vaccinations are postponed. Also, the name, dose and method of administration of the immunoprophylactic drug, as well as the series of vaccine used, are reported in the child's medical record. Subsequently, according to these data, among other things, the reaction of a school student or a kindergarten pupil to vaccination is monitored. The results of the observation are also then entered into the children's medical record.

Data on the passage of scheduled preventive medical examinations by a school student or kindergarten pupil

The sixth section is differentiated into 10 columns, which correlate with the periods of examinations of students (pupils) in different periods their lives:

• before registration in a kindergarten group;
• one year before enrollment in school;
• before the enrollment of the student (pupil) in the school;
• at 7 years old, at 10 years old, at 12 years old, at 14-15 years old, and at 16 and 17 years old.

Data of planned medical examinations (6.1 - before entering a nursery-kindergarten, kindergarten, 6.2 - 1 year before a comprehensive school, 6.3 - before a secondary school)

As part of the mandatory medical examinations, health workers enter in the columns of this section of the child's medical record the results of external and laboratory examinations of the student (pupil):

• Indicators of pressure of the student (pupil) and heart rate
• The final conclusion is that a school student or kindergarten pupil is healthy. If such a conclusion cannot be made, its clinical diagnosis is entered.
• At the passage of each medical examination, a school student or a pupil of a kindergarten must take urine, blood, and feces tests

Based on the results of the medical examination, the examined student (pupil) is assigned to the desired health group. Then follows the conclusion of the conclusion about his state of health - both physical and mental.

The results of the medical prof. consultations

In the section of the form of the child's medical record, dedicated to the results of medical examinations of the student (pupil) and doctor's consultations, information is entered that is based on current data - the results of medical examinations and conclusions after observing children.

Section on the results of medical consultations and recommendations

In the column with the name "Professions" they enter those options for professions that the student (pupil) is going to master and subsequently use, the reference point is his words. The “Recommendations” column contains the conclusion of the district pediatrician, based on an assessment of the state and degree of health of the minor, the problems that the student (pupil) has, the presence of diseases or any deviations, if any.

Each person probably had to visit medical institutions, where one of important documents serves as an outpatient medical card. 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?

As approved in November 2011 federal law 323, 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 prescribed 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 documentation in circulation in outpatient medical institutions. It also states how they are filled.

This is a significant step towards the creation of a medical record. electronic form, 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, an "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 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 past illnesses during the period of 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 certificate, 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.

Examples of frequent violations that will be revealed during checks for the correct filling of outpatient cards. An example of filling out a medical card of an outpatient.

Outpatient card, last changes forms, the order of registration and filling in information, see the article.

In the material we will answer the question: what are the criteria for the quality of filling out the medical card of an outpatient patient now.

We will also give examples of frequent violations that will be revealed during checks for the correct filling of patient cards.

From the article you will learn

An outpatient card is the main accounting medical document of a medical institution providing assistance to citizens in a polyclinic.

note

The Ministry of Health continues to change the procedure for advanced training of medical and pharmaceutical workers. The main changes will come into effect on January 1, 2020. Which doctors should urgently undergo training and what the chief medical officer should do - in the magazine "Deputy Chief Physician".

Changes in the form of an outpatient card

The procedure for maintaining medical documentation is defined in the order of the Ministry of Health of the Russian Federation No. 384n of December 15, 2014.

Particularly important are Annexes 1 and 2, which approved the registration form No. 025 / y “Medical record of a patient receiving medical care on an outpatient basis” and the procedure for its management.

The procedure for maintaining and issuing an outpatient medical record of a patient: a sample

The new form of the outpatient medical record is more detailed and requires the collection of additional data on the patient's health status.

Filling out the outpatient card of the patient is carried out for all persons who appeared at the initial appointment with a specialist of a medical institution.

All attending and consulting physicians of the patient make entries in it.

Medical institutions of phthisiatric, oncological, dermatological, dental, psychiatric and narcological profiles have their own separate accounting forms, therefore, an outpatient card does not start on them.

The registration of the medical card takes place at the reception desk of the polyclinic. It is started in the registry of the institution for all patients who first applied for help.

Title page outpatient medical record includes:

• full name of the medical institution;
• OGRN code;
• individual form number 025 / y.

All outpatient cards are stored in the registry of the polyclinic and are grouped according to the territorial-district principle.

Cards of citizens who can receive certain social services are marked with the letter "L" next to the card number.

The medical record records the nature of the course of the patient's illness, as well as all the performed diagnostic and treatment procedures in a certain sequence.

Also, each subsequent visit of the patient to the clinic is entered into it.

All entries in the map are in Russian. They must be accurate, corrections are not allowed.

Note

Soon it will be necessary to apply clinical recommendations along with the orders and standards of medical care. What is required from the chief medical officer today and will be required tomorrow, read in the magazine "Deputy Chief Physician".

If the doctor needs to correct something, he must certify the correction with his signature. It is possible to record prescribed medicines in Latin.

Items 2-6 outpatient medical record filled in on the basis of data taken from a citizen's passport.

Paragraph 12, which indicates the diagnosis-basis for establishing dispensary observation (according to ICD-10), causes a lot of difficulties and questions for health workers.

Patients who visit several doctors for the same disease require special attention (for example, about diabetes mellitus with a general practitioner and an endocrinologist).

Each of them is written once by the doctor who first registered the patient. If the patient is observed in the clinic due to several unrelated pathologies in one or more narrow specialists, then the name of each of them is indicated in paragraph 12.

What information should be in the patient's outpatient medical record

According to the patient, such items of the outpatient card are filled in as:

1. Education (clause 14):
2. Employment (clause 15):
   • is in the army;
   • pensioner;
   • student;
   • does not work;
   • other.
3. place of work and position (clause 17).

Paragraphs 24-25 determine the order of registration of medical specialists - the corresponding lines are filled in at the first examination of the patient and during his dynamic observation.

Professional records must contain the following information:

• date of inspection;
• place of inspection;
• medical specialty;
• patient complaints;
• medical history;
• lifestyle information;
• objective data;
• main and concomitant diagnoses;
• complications;
• with injuries, poisoning - an external cause of the pathological condition;
• health group;
• the need for dispensary observation;
• medical appointments (including diagnostic procedures and consultations);
• prescribed therapy;
• room sick leave, the timing of issuance;
• issued certificates and prescriptions.

In addition, on primary admission the patient's outpatient card reflects voluntary informed consent to the intervention or refusal of it.

Item 26 of form No. 025 / y - discharge summary. It is filled out when a patient is referred to a CEC or with a period of disability for more than 14 days, signed by the attending physician and includes information about the patient, his condition in dynamics during certain period time based on the results of the examination and therapy.

☆ Read the rules for compiling a discharge summary according to JCI standards in the magazine "Deputy Chief Physician".

However, it is worth noting that in the Procedure for filling out an outpatient medical record, there are no explanations regarding the cases in which it is necessary to fill out a discharge summary.

Two options are possible here - either when referring to a KEK, or when registering temporary disability for more than 14 days. This issue should be resolved at the level of the chief physician of a medical organization.

Paragraph 27 of the outpatient medical card contains information about the consultations of the head. department. However, here the question arises - with what frequency the head. should the department conduct routine consultations with outpatient patients?

There is no answer to it in the orders and resolutions of the Ministry of Health, therefore this issue, like the previous one, is regulated by the internal documents of the institution.

Clause 29 "Conclusion of the medical commission" requires special attention- he reminds health workers that there are a number of issues related to the provision of medical care, the consideration of which is within the competence of the medical commission. In addition, he determines the form of recording her decision in the medical documentation.

Item 35 of the patient's outpatient card - epicrisis.

It is issued in the following cases:

1. Departure to an area served by another medical institution.
2. Fatal outcome.

In the first case, the epicrisis is issued personally to the patient or sent to the clinic where he will be observed. In the second case, this document is postmortem in nature, all illnesses, injuries, interventions, the final posthumous diagnosis (divided into sections) are entered into it.

In addition, the series, number and date of issue of the medical death certificate with a description of all the causes of death indicated in it are indicated. After the death of the patient, the outpatient card is removed from the registry and transferred to the archive, where it is stored for 25 years.

Electronic medical records: findings of colleagues and mistakes

The Ministry of Health plans to increase the number of patients with electronic medical records. Medical organizations will have to gradually switch to legally valid electronic document management and send information on each case of medical care to Personal Area patient "My Health" at EPGU.

How to implement electronic document management

Download the practice-proven algorithm for the implementation of electronic document management, non-disclosure obligation and personal data processing policy in the article of the magazine "Deputy Chief Physician".

Quality criteria for filling out an outpatient card

The patient's individual medical record meets the quality criteria if all sections are filled in and the patient agrees to treatment or refuses it.

The criteria for evaluating the quality of filling include:

1. Registration of records with substantiation of the clinical diagnosis by the data of the patient's interview and diagnostic studies.
2. Availability of data on examinations and consultations department.
3. The presence of a decision of a medical council, commission, etc.

Outpatient card of the patient: content

The information that should be included in the outpatient medical record is presented in the table below:

Common defects when filling out an outpatient card

The main violations committed when filling out an outpatient medical card include:

• lack of written consent of the patient to treatment or refusal of it (sanction - reduction of payment for treatment by 10% of the established tariff);
• corrections, additions, inserts, a rewritten case history (sanction - a reduction in the amount of payment for treatment by 90% of the established tariff).