Each person must have visited hospitals, where one of the most important documents is an outpatient medical record. Neither the doctor nor the patient can do without it.
What is an outpatient card for?
The extent to which this document is correctly filled out may determine the fate of the patient within the framework of a criminal investigation or civil case that is possibly being investigated.
An extract from an outpatient card is required:
⦁ when conducting forensic medical examinations;
⦁ for settlements on payment for the provision of medical care under compulsory medical insurance contracts;
⦁ for conducting medical and economic examinations to monitor the quality of medical services performed.
What is an outpatient card of a patient?
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 preventive, treatment, diagnostic and sanitary hygiene measures.
Medical documentation is accounting, reporting and accounting and settlement. An outpatient medical record belongs to the first category. It describes the diagnoses, the current condition of the patient, and recommendations for treatment.
Introduction of an updated form
Order of the Russian Ministry of Health No. 834 of December 2014 approved updated standardized forms of documentation in circulation of outpatient medical facilities. It also spells out 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, the form No. 025 / y - "Medical record of an outpatient patient" was developed, and it is described in detail how to fill it out. In addition, a sample of a patient coupon with an appropriate filling order has been approved.
By the aforementioned order, this card was given the status of the main accounting medical document of an institution providing medical care for adults using outpatient conditions.
What is the difference from the old form?
In the new accounting form, the information content has been significantly increased, the positions to be filled are specified in more detail. In the previous version, the doctor could make notes at his discretion, now they are unified.
Be sure to include information:
⦁ on consultations of narrow medical specialists and department head;
⦁ the result of the meeting of the WCC;
⦁ about carrying out x-ray pictures;
⦁ on the diagnosis of the 10th International Qualification of Diseases.
For each specialized medical institution or their specialized structural direction in dentistry, oncology, dermatology, psychology, orthodontics, psychiatry and narcology, an outpatient card has been developed. Form No. 043-1 / y, for example, is filled out for orthodontic patients, No. 030 / y is intended for a control card for follow-up observation.
Form No. 030-1 / у-02 is started for persons suffering from psychiatric diseases and drug addiction. It is 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 person’s visit to the clinic, the registry fills in the data on the title page.But the patient's outpatient card can only be filled out by doctors.
If the patient belongs to the category of federal beneficiaries, “L” is affixed to the card number. The doctor must make an appropriate record of each visit to the clinic patients.
Outpatient card reflects:
⦁ how the disease proceeds;
⦁ what diagnostic and therapeutic measures are consistently carried out by the attending physician.
Recording is carried out carefully, in Russian, in the appropriate section without any abbreviations. If you need to fix something, this is done immediately after making a mistake and must be certified with a medical signature.
It is permissible to use Latin to record the names of medicines.
The first sheet in the registry, the health worker fills out according to the data from the patient's identity documents. Graphs of the workplace and position are recorded according to the patient. The form has recommendations for completing each section.
Filling principles
When an outpatient card is filled in, some basic principles should be kept in mind.
It should describe in chronological order:
⦁ in what condition did the patient come to see a doctor;
⦁ what diagnostic and treatment procedures have been performed;
⦁ treatment results;
⦁ circumstances of a physical, social and other nature that affect the patient during pathological changes in his 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 filling out the form.
An outpatient card consists of forms on which long-term and operational information is recorded.
The long-term information contained on the front-glued sheets includes:
⦁ information copied from an identity document;
⦁ blood group with a Rhesus factor;
⦁ information on past infectious diseases and allergic reactions;
⦁ final diagnoses;
⦁ results of preventive examinations;
⦁ list of prescribed narcotic drugs.
Operational information is entered on the inserts, where the results of the initial treatment and secondary visits to the local therapist, narrow-profile doctors, consultations with the head of the department are recorded.
Extract from an outpatient card
An extract is a medical certificate about the state of health in the form 027 / у, which refers to the second group of medical records. It contains information about past illnesses during the outpatient treatment period.
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 link the individual stages of the sanitary-preventive and therapeutic measures.
An extract may be provided by the patient to the employer to inform them about outpatient care. It is not subject to payment, but is handed over along with a sick leave, if the latter is issued for more than a month.
This document allows you to free from classes in educational institutions.
The extract contains information about the patient with the number of the medical policy, a list of his complaints, the symptoms of the disease, the results of medical examinations and examinations, as well as the initial diagnosis.
All information should be fully consistent with the one that the outpatient card contains.
The extract can be used to prescribe further medical procedures.
