Registration form 025 for the patient’s medical card. Patient's outpatient card: description, form, sample and extract
Country support:
operating system:Windows
Family: Universal Accounting System
Purpose: Business automation
Outpatient card form 025 y
Main features of the program:
The program can be translated into any language convenient for you. In addition, you can work with several languages at once
The program allows you to keep an electronic medical history
The program includes academic knowledge with a categorized list of ICD diagnoses
For various ICD diagnoses, a plan for the required examination and treatment has already been drawn up
All test results can also be stored in the program
Setting up filling out templates for research will help optimize the work of all your specialists and eliminate paper documentation
You can attach pictures and any files to the patient’s history
Any company form in MS Word format can be set as a template to fill out
To avoid waiting in line for patients to be seen, you can use pre-registration
The program will even be able to call on behalf of your organization and tell the patient any important information
It is possible to use discount cards
Automatic and manual write-off of medications and materials for research is supported. Sales in pharmacy mode
For all services, you can set up calculations, and then consumables will be debited automatically
Modern system for working with patients will help employees complete all important tasks on time
You will be able to watch how quickly your client base grows and attract new patients with the help of modern capabilities programs
You will find out on which days of the week or days of the month you have the most patients, this will make it easy to manage the workload of each department
The system will show which patients brought you the most profit, and you can easily reward such clients with a personal price list or bonuses
The report will show which patients have not paid for their purchases in full or which suppliers you have not yet fully paid
Every marketing decision you make will be taken into account and analyzed based on the number of new patients and payments
Managers will be able to easily find out which clients you haven’t had for a long time and contact them immediately
Statistics on reasons for leaving will help you avoid patient churn
Your specialists can be easily compared by various criteria: number of patients, services provided, profits and productivity
You will find out which doctors see patients more often and who may lose your clients
Piecework wages specialists are easily calculated automatically taking into account personal rates
For each doctor or department, you can find out the dynamics of growth in visits and services for any period
A special report will show the most profitable or popular services
You can find out all the statistics on patients, services and specialists for any convenient period of time and evaluate the dynamics using visual reports
You will receive complete statistics on goods sold or spent on services
For each medicine or product, the program will tell you how long its reserves will last, which will allow you to optimize purchases and storage
The purchasing power report will show the financial capabilities of your customers depending on each branch
All financial movements will be under your complete control. You can easily track what you spend the most money on for any period
Analyzing payments according to the values you need will help you decide whether to increase or decrease prices for services and goods
Integration with the latest technologies will allow you to shock your clients and deservedly gain the reputation of the most modern company
Clients will be able to make an appointment on your website with any employee in the selected branch. Current schedule and prices for services
Your patients will be able to find out about the readiness of tests on the website and download the results in personal account
The ultra-modern function of communication with a PBX will allow you to see the caller’s data, shock the client by immediately addressing him by name, and not waste a second searching for information
Reliable control will be ensured by integration with cameras: the program will indicate data on the sale, payment received and other important information in the captions of the video stream
Connection with payment terminals so that clients can pay for their services not only at the branch, but also at the nearest terminal. Such payments will be automatically displayed in the program
Payment
terminals
By installing a screen with a visual schedule for employees and offices, you will undoubtedly raise the prestige of your company in the eyes of clients and increase your own control
You can implement customer assessment of the quality of work. The client will receive an SMS in which he will be asked to evaluate the work of the employees. The manager will be able to view the analysis of SMS voting in the program
Special program will save a scheduled copy of all your data in the program without the need to stop working in the system, automatically archive and notify you when it is ready
Reserve
copying
The planning system allows you to set up a backup schedule, receive important reports strictly in certain time and set any other program actions
You can quickly enter the initial data necessary for the program to work. This is done using convenient manual data entry or import.
The program interface is so easy that even a child can quickly figure it out.
We have completed business automation for many organizations:
Language basic version programs: RUSSIAN
You can also order an international version of the program, into which you can enter information in ANY LANGUAGE of the world. You can even easily translate the interface yourself, since all the names will be placed in a separate text file.
Outpatient card form 025 y is medical card client taking the course outpatient treatment. The patient's outpatient card form 025 is the main document for registration various procedures provided by the medical treatment center as part of the examination and treatment of its client.
An outpatient medical record, form 025, is drawn up by the medical treatment center upon direct contact from the client and contains a description of his condition, treatment course, set of procedures, step-by-step chronology and results.
Outpatient card form 025 y 04 is the same client’s medical card, the format of which was approved by the ministry health care in 2004 and is still used today, where the number “04” was omitted for brevity. Outpatient card form 025 04 is used in all treatment and medical centers providing outpatient services and is marked by district affiliation.
You can download the outpatient card form 025 у (025/у-04) on the website - the website of the company "Universal Accounting System" (USU), the developer of the specialized software For medical institutions. Outpatient card form 025 y 04, which the USU offers to download in its demo version, is filled out in accordance with the instructions developed by the Ministry of Health, which shows step by step how to fill it out.
The rules for filling out an outpatient card, form 025 y (025/y-04), describe which numbered line should contain what information, and also give recommendations on what actions should be taken when maintaining it in the event of any changes in the client’s records or condition.
An outpatient medical record, form 025 y 04, must be kept at the reception desk of the medical treatment center.
Outpatient card form 025 u can download the form on the website website; upon hospitalization, the patient is admitted to inpatient department and is contained inside his stationary card. When checking out the client's card outpatient form 025/у (025/у-04) is returned back – to medical treatment center at his place of residence.
The outpatient card, form 025, which is offered for download on the website, requires great attention to filling out the sheet of final diagnoses, where specialists of different profiles indicate the diagnoses they made in the current year.
The medical record of an outpatient patient, form 025, establishes the procedure for the doctor’s actions when he cannot accurately determine the disease - then on the current page of the outpatient record of form 025/u (025/u-04) he notes his presumed diagnosis, and on the sheet of final diagnoses he records only the date of the first appointment, against which the later diagnosis is indicated. Outpatient medical record form 025 y (025/y-04) allows you to correct an inaccurate diagnosis by crossing it out and recording the updated one against the same date of registration of the visit.
The Ministry of Health rarely makes significant changes to medical documentation, here we go latest version Kazakhstan approved the form 025 outpatient card in November 2010.
In order for Form 025 to be completed and/or issued by the registry, an outpatient card must be presented.
Outpatient coupon form 025 1 contains information about the patient who wishes to receive medical care outpatient. The information also includes data on the attending physician’s appointment hours, the patient’s illness, registration at the dispensary, facts of temporary disability that occurred, etc.
Outpatient coupon form 025 12 y - this is the previous type of coupon, which has already lost its force; it was replaced by format 025-1/u in 2014.
The outpatient card form 025-1/у is filled out using data from the outpatient card form 025/у (025/у-04) by entering or underlining the desired option from the proposed answers in the coupon itself.
The program can be used by:
Medical center
And private clinic
Clinic
and outpatient clinic
State
hospital, hospital
and hospital
Laboratory and
diagnostic and treatment
center
Sanatorium and
rehabilitation
center
Dispensary
and preventive
center
Private practitioners
doctors
Eye center
and optics
Reproductive,
perinatal
center and maternity hospital
Plastic and
aesthetic
surgery
Research Institute - scientific-
research
institute
Psychologists
and trainings
Women's
consultation
Wellness
complex
and center
Surgical
center
Preschool educational institution, logo center
and speech pathologist
Any other
organization
Video programs for outpatient card form 025 y
By watching the following video, you can quickly familiarize yourself with the capabilities of the USU program - the Universal Accounting System. If you do not see the video uploaded to YouTube, be sure to write to us, we will find another way to show the demo video!
Anatoly Wasserman presents the new version 5.0 of the USU program
In addition to opinions about the USU program ordinary users Expert opinions are now presented to your attention. Anatoly Wasserman was born on December 9, 1952. Graduated from the Odessa Technological Institute of Refrigeration Industry, majoring in engineering. After graduation, he worked as a programmer. Then - a system programmer. He first appeared on screen in 1989 in the club “What? Where? When?", then - at the Brain Ring. In the television “Own Game” he won fifteen victories in a row in 2001-2002 and became the best player of the decade in 2004. Five-time Ukrainian champion sports version"Your own game." Four-time champion of Moscow in the sports version of “My Game”, bronze medalist of the same competition, silver in 2017. Silver medalist of the “Connoisseur Games” - the World Games of Connoisseurs - 2010 in “Your Game”.
Supplement to the program for professional managers - The Bible of the Modern Leader
Addition to the program for professional managers: to develop business and increase income. A unique product developed at the intersection of two sciences: economics and information technology. There are no analogues
With the development of technology, life speeds up. You need to be on time everywhere - because the faster you do things, the more you earn. For this reason, it is very important to have a feature-rich mobile application at hand.
Alexander Druz about the Universal Accounting System
In addition to the opinions of ordinary users about the USU program, the opinions of experts are now presented to your attention. Alexander Druz is the first master of the intellectual game "ChGK". He was awarded the Crystal Owl prize six times as the club's best player. Winner of the "Diamond Owl" - a prize for the best player. Champion of the television version of the Brain Ring. IN television program“Own Game” won “Line Games”, “Super Cup”, won the “III Challenge Cup” with the team, and set an absolute record for performance in one game. Author and presenter mind games and educational programs on various TV channels.
Maxim Potashev on the effectiveness of the USU program
In addition to the opinions of ordinary users about the USU program, the opinions of experts are now presented to your attention. Maxim Potashev - master of the game “What? Where? When?”, four-time winner of the “Crystal Owl” prize, twice world champion, three-time Russian champion, six-time Moscow champion, three-time winner of the Moscow Open Championship in the game “ChGK”. Based on the results of a general audience vote in 2000, he was recognized as the best player in the entire 25 years of the elite club’s existence. 50 thousand viewers of the program voted for the candidacy of Maxim Potashev. He received the “Big Crystal Owl” and the main prize of the anniversary games - the “Diamond Star” of the master of the game. Member of the Board and since 2001 - Vice President International Association clubs. By profession - mathematician, marketer, business coach. Graduated from the Faculty of Management and Applied Mathematics, taught at the Department of General and Applied Economics at MIPT. In August 2010, he was elected president of the All-Russian public organization"Federation of Sports Bridge of Russia." He heads a consulting company that helps various organizations solve problems related to sales, marketing, customer service and business process optimization.
Sergey Karyakin about tactics in business
In addition to the opinions of ordinary users about the USU program, the opinions of experts are now presented to your attention. Sergey Karyakin. At the age of 12 he became the youngest grandmaster in human history. Included in the Guinness Book of Records. Won the Candidates Tournament. Winner of the FIDE World Cup. World champion in rapid chess, world champion in blitz. Honored Master of Sports of Ukraine. Honored Master of Sports of Russia, Grandmaster of Russia. Awarded the Order of Merit, III degree. Member of the Public Chamber Russian Federation VI composition. Repeated winner of children's and youth world and European championships. Winner and medalist of a number of major tournaments. Champion of the XXXVI World Chess Olympiad as a member of the Ukrainian team, silver medalist of the Olympics as a member of the Russian team. He showed the best result on his board and received the first individual prize (on board 4). Champion of Russia with best result on the 1st board. World champion in the Russian national team. World Cup semi-finalist. Winner of a number of international tournaments.
Name of medical organization Form code according to OKUD __________
Organization code according to OKPO ___________
Medical documentation
Registration form N 025/у
Address ______________________________ Approved by order of the Russian Ministry of Health
MEDICAL CARD
A PATIENT RECEIVING MEDICAL CARE
IN OUTPATIENT CONDITIONS N _____
1. Date of filling out the medical record: date ___ month _____ year _____
2. Last name, first name, patronymic _________________________________________________
3. Gender: male - 1, female - 2 4. Date of birth: date ___ month ___ year ___
5. Place of registration: subject of the Russian Federation ________________________
district _____________ city ________________ locality _______________
street _______________ house _________ apartment ________ tel. ________________
6. Location: urban - 1, rural - 2.
7. Compulsory medical insurance policy: series __________ N ______________ 8. SNILS __________________
9. Name of medical insurance organization _________________________
12. Diseases for which it is carried out dispensary observation:
Start date of dispensary observation |
Date of termination of clinical observation |
ICD-10 code | ||
page 2 f. N 025/у
13. Marital status: registered marriage - 1, not married
married - 2, unknown - 3.
14. Education: professional: higher - 1, secondary - 2; overall: average
3, basic - 4, initial - 5; unknown - 6.
15. Employment: working - 1, doing military service and equivalent
service - 2; pensioner - 3, student - 4, not working - 5, others -
16. Disability (primary, repeated, group, date) _____________________
17. Place of work, position ________________________________________________
18. Change of place of work ________________________________________________
19. Change of place of registration _________________________________________________
20. Recording sheet for final (refined) diagnoses:
Date (day, month, year) |
Final (refined) diagnoses |
Installed for the first time or again (+/-) | |
21. Blood type ____ 22. Rh factor ____ 23. Allergic reactions ________
page 3 f. N 025/у
24. Records of medical specialists:
Date of examination _________ at the reception, at home, at the paramedic-midwife station,
Doctor (specialty) ___________
Patient complaints _________________________________________________________________
___________________________________________________________________________
History of illness, life ________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Objective data ______________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
ICD-10 code ______
ICD-10 code ______
Health group ________ Dispensary observation ______________________
Discount recipes |
|
Informed voluntary consent for medical intervention, refusal of medical intervention |
|
page 4 f. N 025/у
25. Medical observation over time:
Observation data over time |
|
Appointments (research, consultations) |
Medicines, physiotherapy |
Certificate of incapacity for work, certificate |
Discount recipes |
Observation data over time |
|
Appointments (research, consultations) |
Medicines, physiotherapy |
Certificate of incapacity for work, certificate |
Discount recipes |
page 5 f. N 025/у
Observation data over time |
|
Appointments (research, consultations) |
Medicines, physiotherapy |
Certificate of incapacity for work, certificate |
Discount recipes |
Observation data over time |
|
Appointments (research, consultations) |
Medicines, physiotherapy |
Certificate of incapacity for work, certificate |
Discount recipes |
page 6 f. N 025/у
Observation data over time |
|
Appointments (research, consultations) |
Medicines, physiotherapy |
Certificate of incapacity for work, certificate |
Discount recipes |
Observation data over time |
|
Appointments (research, consultations) |
Medicines, physiotherapy |
Certificate of incapacity for work, certificate |
Discount recipes |
page 7 f. N 025/у
26. Stage epicrisis
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Diagnosis of the underlying disease: _______________________ code according to ICD-10 ______
___________________________________________________________________________
Complications: _______________________________________________________________
___________________________________________________________________________
Concomitant diseases ____________________________ ICD-10 code ______
ICD-10 code ______
ICD-10 code ______
External cause for injuries (poisoning) _________________________________
ICD-10 code ______
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Doctor _______________
page 8 f. N 025/у
27. Consultation with the head of the department
Date _________ Temporary disability from _______ (____ days).
Complaints and dynamics of the condition ________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Examination and treatment performed ________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Diagnosis of the underlying disease: _______________________ code according to ICD-10 ______
___________________________________________________________________________
Complications: _______________________________________________________________
___________________________________________________________________________
Concomitant diseases ____________________________ ICD-10 code ______
ICD-10 code ______
ICD-10 code ______
External cause for injuries (poisoning) _________________________________
ICD-10 code ______
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Certificate of incapacity for work _________________________________________________
Head department _______________ Attending physician ______________________________
page 9 f. N 025/у
28. Conclusion of the medical commission
Date ____________
Complaints and dynamics of the condition ________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Examination and treatment performed ________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Diagnosis of the underlying disease: _______________________ code according to ICD-10 ______
___________________________________________________________________________
Complications: _______________________________________________________________
___________________________________________________________________________
Concomitant diseases ____________________________ ICD-10 code ______
ICD-10 code ______
ICD-10 code ______
External cause for injuries (poisoning) _________________________________
ICD-10 code ______
Conclusion of the medical commission: _____________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Chairman _____________ Commission members _________________________________
page 10 f. N 025/у
29. Clinical observation
Date ____________
Complaints and dynamics of the condition ________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Treatment and preventive measures carried out ___________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Diagnosis of the underlying disease: _______________________ code according to ICD-10 ______
___________________________________________________________________________
Complications: _______________________________________________________________
___________________________________________________________________________
Concomitant diseases ____________________________ ICD-10 code ______
ICD-10 code ______
ICD-10 code ______
External cause for injuries (poisoning) _________________________________
ICD-10 code ______
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Doctor _______________
page 11 f. N 025/у
30. Information about hospitalizations
31. Information about surgical interventions performed in outpatient
conditions
32. Sheet for recording radiation doses during x-ray examinations
page 12 f. N 025/у
33. Results functional methods research:
page 13 f. N 025/у
34. Results of laboratory research methods.
Such a card is filled out by the registrar of any medical institution providing treatment to patients. When a person goes to the clinic for the first time, he needs to present his passport, and a medical card is issued for him. It is then stored in the registry of the medical institution.
Extract from the medical record of an outpatient
If a person is scheduled to have a consultation with a specialist who is seeing him in another medical institution, he will need to provide an extract from his permanent card. To do this, you need to visit a doctor and order such a document. This procedure requires additional time.
Buy an outpatient medical card
Often, the patient’s life and health depend on how quickly assistance is provided or surgery is performed. To receive an extract from your card, you need to waste a lot of time. We offer the opportunity to buy an outpatient medical card, an inpatient medical card.
Filling out an outpatient medical record
Our specialists are very careful when preparing medical books, certificates, and documentation, so an outpatient medical card purchased from us in Moscow will contain everything necessary information about the patient, clearly indicated diagnoses. Such a document will contain all degrees of protection, seals and signatures of the attending physicians.
Insert sheet for an outpatient medical record
The card itself contains small quantity sheets, therefore, if there is not enough space, loose sheets are used. They must be securely attached.
New outpatient medical record
We offer the service of issuing such a medical card. You need to call and place an order. Our specialists will immediately begin work. On the same day, the completed new outpatient medical record will be in your hands.
With such a document, you will be able to apply to any medical institution and continue treatment with the selected specialist. Delivery is carried out using a courier service.
Medical record of an outpatient in cosmetology
Often many patients experience allergic reactions for certain groups of medications, so some cosmetics contraindicated for such a client. An experienced cosmetologist always keeps a special card to know about medical contraindications your patient.
Outpatient medical record 2015
Introduced this year new look cards required for use in medical institutions. They also reflect the necessary information about the patient, previous diseases, test results, and vaccinations performed. They also contain records of doctors examining the patient.
Outpatient medical record 025 u
We will be able to produce such a card on the day of your request, it will be filled out in accordance with the current legislation of Russia.
The patient's medical record, form 025, is the source material for issuing various types of certificates necessary for entering work, studying or leaving the country.
Medical card 025 y 04
It is issued at a medical institution and is provided for each patient. We offer to buy such a card inexpensively and arrange delivery to any district of Moscow.
Medical card 025 u in Moscow
Moscow - big city, therefore, many different medical institutions are open, and it will take a very long time to obtain any document. We offer medical record production services. Such a document is prepared quickly, is legal and can be presented to any doctor.
Medical card 025 from doctors
Medical record 025 contains all information about the patient. Man passes medical examinations, visits specialists, ophthalmologists, endocrinologists. Each doctor makes his own notes on the document, stamps and signs. When accessing again, new entries appear. Such a map is the history of each person’s treatment.
Medical card 025 buy
If the card is urgently needed, for example, you moved to Moscow from another city. You can buy this form from us. The order is placed over the phone, then we independently process all medical records.
We offer affordable price, because all the doctors are on site. These are real doctors, we guarantee the authenticity of the issued document.
Outpatient medical record form 025
Such a card will allow you to complete the required legal formalities and continue treatment in any medical institution.
Our medical card form 025 has a low cost, so it is available to anyone. We produce the document on the day the order is placed. You don't even have to come. You need to provide us with your information, and we will issue the document without your participation.
When such a card is ready, our administrator will call you back. Next, the courier will deliver the already completed card to any location you choose.
Here you will find:
Outpatient patient card form 025 y is the main document of a patient in an outpatient facility, intended for internal use. The card contains all the important information about the patient necessary to carry out healing process in full. The document is drawn up at the reception desk upon the patient’s initial visit. This is where the title page is drawn up.
The outpatient card form is Appendix No. 1 to the order of the Ministry of Health No. 834n, issued in 2014, and is currently used in this form. The document contains 14 pages and includes 35 points for entering data. The medical outpatient card form is also filled out in accordance with the above order. Regulates the procedure for filling out Appendix No. 2.
Medical outpatient card form 025 must contain all passport data about the patient, including marital status. This is part of the basic information that is relevant in the long term (i.e., unchanged for quite a long time or throughout life). These also include: blood type, Rh factor information compulsory medical insurance policy, availability of benefits and those already available to the patient chronic diseases, allergic reactions, disability.
Completeness and accuracy of data entry plays a role important role in making diagnoses and prescribing treatment. Flaw important information, for example, the presence of allergic reactions can lead to serious negative consequences and cause harm to the health and life of the patient.
Medical card form 025u is a registration form of an organization providing outpatient care to the adult population. This form is not filled out by a number of specialized medical organizations that have their own registration forms (see the list in Appendix 2 of Order No. 834n). The data in the form is entered by paramedical workers and doctors conducting treatment.
Outpatient medical record (form 025 y) – storage of operational data
Operational data includes all information that is received in the process of treating a patient, starting with the initial visit to a specialist. The card reflects the results of examinations, established diagnoses, prescribed procedures and necessary medications. All repeat visits and medical observations over time are subject to recording.
The patient's outpatient card may also contain information about the patient's consultation with the head of the department. Columns are provided for recording the conclusions of the medical commission. The medical outpatient record must contain all the patient's test results. Forms with results are filed on a specially designated sheet. The results of laboratory and functional research methods are attached.
Registration form 025 contains an epicrisis - an assessment of the patient’s condition, the diagnosis made, a description of the reasons for the development of the disease, the rationale for the prescribed treatment, and the results obtained. There are generally accepted patterns in writing an epicrisis. It is written this conclusion attending physician.
You can buy an outpatient card form 025 in our online store. You can purchase from 1 copy. The price is indicated for one unit of goods. When adding the number of card copies, the final cost is calculated automatically. Printing is carried out in the City Blank printing house. The document fully complies with the established form.
Delivery of products is carried out using a courier service. Courier delivery is possible in the Moscow region. You can select the method of payment and receipt of goods when ordering.
Expand ▼
Form Medical record of a patient receiving medical care in outpatient setting(N 025/у) corresponds Appendix 1 to.
In return:
Procedure for filling out the registration form N 025/у "Patient's medical record,receiving medical care on an outpatient basis"
1. Registration form N 025/у " Medical record of a patient receiving medical care in an outpatient setting" is the main account medical document a medical organization providing medical care on an outpatient basis to the adult population.
2. Map filled out for each patient seeking outpatient medical care for the first time. For each patient in a medical organization or its structural unit providing medical care on an outpatient basis, fill out one Map, no matter how many doctors provide treatment.
3. Cards are not carried out on patients(s) seeking medical care on an outpatient basis in specialized medical organizations or their structural divisions in the profiles of oncology, phthisiology, psychiatry, psychiatry-narcology, dermatology, dentistry and orthodontics, who fill out their registration forms.
4. Map filled out by doctors medical workers with average vocational education Those conducting independent appointments fill out a logbook for patients receiving medical care on an outpatient basis.
5. Cards in the registry of a medical organization are grouped according to the local principle, Cards citizens eligible to receive the kit social services, are marked with the letter "L" (next to the number Cards).
6. Title page Cards is filled out at the registry of a medical organization when a patient first seeks medical care.
7. On title page Cards the full name of the medical organization is indicated in accordance with its constituent documents, OGRN code, and the number is indicated Cards- individual account number Kart, established by a medical organization.
8. B Map reflects the nature of the course of the disease (trauma, poisoning), as well as all diagnostic and therapeutic measures, carried out by the attending physician, recorded in their sequence.
9. Map filled out for each patient visit. Underway Map by filling out the appropriate sections.
10. Entries are made in Russian, neatly, without abbreviations, all necessary in Map corrections are carried out immediately, confirmed by the signature of the doctor filling out Map. It is allowed to record names medicines in Latin.
11. When filling Cards:
11.1. In paragraph 1 put the date primary filling Cards.
Points 2 - 6 Cards are filled out based on the information contained in the patient’s identity document.
11.2. Item 7 includes series and number insurance policy compulsory health insurance, paragraph 8 - insurance number of an individual personal account (SNILS), paragraph 9 - name of the medical insurance organization.
11.3. Paragraph 10 indicates the benefit category code in accordance with the categories of citizens entitled to receive state social assistance in the form of a set of social services<1>:
"1" - war invalids;
"2" - participants in the Great Patriotic War;
"3" - combat veterans from among the persons specified in subparagraphs 1 - 4 of paragraph 1 of Article 3 "
"4" - military personnel who passed military service V military units, institutions, military educational institutions who were not part of the active army, in the period from June 22, 1941 to September 3, 1945 for at least six months, military personnel, awarded with orders or USSR medals for service during the specified period;
“5” - persons awarded the badge “Resident of besieged Leningrad”;
“6” - persons who worked during the Great Patriotic War at air defense facilities, local air defense facilities, in the construction of defensive structures, naval bases, airfields and other military facilities within the rear boundaries of active fronts, operational zones of active fleets, at front lines sections of railways and highways, as well as crew members of transport fleet ships interned at the beginning of the Great Patriotic War in the ports of other states;
"7" - members of the families of fallen (deceased) war invalids, participants of the Great Patriotic War and combat veterans, members of the families of those killed in the Great Patriotic War Patriotic War persons from among personnel self-defense groups of facility and emergency teams of local air defense, as well as family members of deceased hospital workers in the city of Leningrad;
"8" - disabled people;
"9" - disabled children.
11.4. Paragraph 11 indicates the patient’s identity document.
11.5. Paragraph 12 indicates the diseases (injuries) for which dispensary observation of the patient is carried out, and their code according to the International Statistical Classification of Diseases and Related Health Problems, tenth revision (hereinafter referred to as ICD-10).
If the patient is under dispensary observation for the same disease by several medical specialists (for example, peptic ulcer from a general practitioner and a surgeon), each such disease is indicated once by the medical specialist who first established the dispensary observation. If the patient is observed for several etiological reasons related diseases from one or more medical specialists, then each of the diseases is noted in paragraph 12.
11.6. In paragraph 13 “Marital status,” a record is made of whether the patient is married or unmarried, based on the information contained in the patient’s identity document. If there is no information, "unknown" is indicated.
11.7. Item 14 “Education” is filled out from the patient’s words:
in the position “professional”, “higher”, “secondary” are indicated;
in the “general” position, “average”, “basic”, “initial” are indicated.
11.8. Item 15 “Employment” is filled out from the words of the patient or relatives:
The position “carrying out military service or equivalent service” indicates persons undergoing military service<1>or a service equivalent to it; The position “other” includes persons who are engaged in household work and persons without a fixed place of residence.
11.9. If the patient has a disability, in paragraph 16 indicate “for the first time” or “repeatedly”, the group of disability and the date of its establishment.
11.10. In paragraph 17, according to the patient, the place of work or position is indicated.
11.11. In case of a change in place of work and (or) place of residence, the corresponding changes are indicated in paragraphs 18 and 19.
11.12. Paragraph 20 indicates all newly established final (refined) diagnoses and full name. doctor
11.13. In paragraphs 21 and 22, the blood type and Rh factor are noted, and in paragraph 23, allergic reactions that the patient had previously had.
11.14. In paragraph 24, records of medical specialists are made by filling out the appropriate lines.
11.15. Item 25 is used to record the patient’s condition during observation over time.
11.16. Paragraph 26 contains a stage-by-stage epicrisis, paragraph 27 - information about the consultation with the head of the department of a medical organization, paragraph 28 - the conclusion of the medical commission 11.17. Data about the patient(s) for whom dispensary observation is being carried out is recorded in paragraph 29.
11.18. Paragraph 30 contains information about hospitalizations performed, paragraph 31 - information about surgical interventions performed, paragraph 32 - information about radiation doses received during X-ray examinations.
11.19. On the pages corresponding to paragraphs 33 and 34, the results of functional and laboratory studies are pasted.
11.20. Point 35 is used to record the epicrisis. An epicrisis is issued in the event of leaving the service area of a medical organization or in the event of death (posthumous epicrisis).
In case of disposal, the epicrisis is sent to medical organization at the place of medical observation of the patient (s) or handed over to the patient (s).
In the event of the death of the patient, a post-mortem epicrisis is drawn up, which reflects all previous diseases, injuries, operations, a post-mortem final rubricated (divided into sections) diagnosis is made; the series, number and date of issue of the registration form are indicated, and all causes of death recorded in it are also indicated.
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