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Medical examination by an ENT doctor and correct filling of the form. Universal template for initial medical examination

Work of an otorhinolaryngologist in the clinic is associated with maintaining certain medical records in accordance with Order of the Ministry of Health No. 1030 “On approval of forms of primary medical documentation of healthcare institutions” and the Instruction on the procedure for recording visits to doctors and nursing staff in medical institutions (Letter of the Ministry of Health No. 08- 14/9-14), regulating the work of medical personnel and designed to make it more efficient.
Doctor Any specialty in its area of ​​work is a health care organizer, so it is necessary to know some information about medical documentation and the rules for filling it out.

Main document at an outpatient appointment, the outpatient’s medical card is used. It reflects: passport data, results of annual preventive medical examinations, results of dynamic dispensary observation, examination and treatment, data on current medical observation and treatment, information on temporary disability for all diseases with which the patient went to the clinic, records of inpatient treatment and others medical information about the patient.

Records are kept in chronological order, they must be clear and concise. First, the date of examination, research or consultation is set. When providing assistance at home, in addition to the date, the time is also indicated. During a preventive examination, a “preventive examination by an ENT doctor” is indicated before the appointment. The following is a description of the condition of the ENT organs, a diagnosis is established, a group for dispensary registration is determined, and recommendations are given.

If you sick during the examination, certain medications were detected, a note about this is placed on the front cover of the medical card. In this case, it is advisable to refer the patient for examination (consultation) to an allergist.

When contacting sick When visiting a doctor in connection with a disease, the patient’s complaints, anamnesis, examination data and additional examination methods (tests, x-rays, etc.) are entered into the outpatient card. All this allows us to substantiate the diagnosis that is established for the patient. The card also makes a note about the mode (outpatient, bed), treatment, and the date of the next visit to the doctor.

Besides, in the medical record There is a sheet for final (refined) diagnoses, in which they are written out. When diagnosing an acute disease, the date of its establishment is indicated and a “+” mark is made. For chronic diseases, a revised diagnosis is made once a calendar year and is marked with a “-”. The “+” sign is marked only in the case of a diagnosis of a chronic disease detected for the first time in life.

If the condition health The patient is such that he needs to be relieved from performing official duties, then he is issued a certificate of temporary incapacity for work, and the medical record indicates the date of release and the date of the patient’s next appearance to the doctor or an active visit to his home. The rules for assessing work capacity and preparing relevant medical documentation are covered in a special chapter.

At referral of the patient For hospitalization in a hospital, a corresponding entry is made in the outpatient card indicating the diagnosis and justification for the need for hospitalization and a special accounting form is filled out.
On outpatient appointment it is necessary to fill out a statistical form in which information about the patient and the established diagnosis is entered. It is completed by a nurse.

In addition to those indicated documents When a chronic patient is identified who needs dynamic dispensary observation, a special registration form is filled out.
By end of the working day the doctor fills out the columns of the statistical diary. All documents and records of the doctor are certified by his signature.

Certificates and extracts from medical records patients are issued only upon official requests from medical institutions, investigative bodies, prosecutors and authorities (Article 61. Medical confidentiality “Fundamentals of the legislation of the Russian Federation “On the protection of the health of citizens”), signed by the attending physician, head of the department (office) and chief physician or his deputy. In this case, a mark must be made on the card and a second copy of the issued document is pasted in.

To analyze the work of the office(departments) as a whole and to evaluate the activities of each doctor individually, it is advisable to keep the following logs (with a decentralized registration system):
- operating;
- directed to hospitalization;
- house calls;
- sent for consultation;
- procedural;
- sanitary educational work;
- issuance and extension of certificates of incapacity for work;
- biopsy material;
- comments on the management of patients (based on monitoring the preparation of outpatient cards).

1. Nose and paranasal sinuses: upon external examination, the shape of the nose is not changed (there is no deviation of the nasal dorsum from the midline, no retraction is noted), palpation of the external nose is painless, when palpating the area of ​​the paranasal sinuses, the patient notes the exit point of the V pair of cranial nerves soreness; nasal breathing is difficult through both halves, more so on the right, the sense of smell is weakened.

Anterior rhinoscopy: the vestibule of the nose is free, the nasal septum is deviated to the right, the mucous membrane is pale, swollen, there are polyps in the middle meatus on both sides, the inferior turbinate on the right is increased in volume, thick mucous discharge in the middle meatus.

2. Pharynx. Oral cavity: the oral mucosa is pink, the tongue is not coated, there are no traces of teeth, the condition of the teeth is satisfactory. Oral part of the pharynx (pharyngoscopy): the tonsil niches are deep, the tonsils are reduced in size, not hyperemic, without pathological contents in the lacunae. The soft palate and palatine arches are without pathological changes. The condition of the mucous membrane of the posterior wall of the pharynx is without pathological changes. The cervical lymph nodes are not enlarged, slightly palpable. Nasal part of the pharynx (posterior rhinoscopy): the nasopharynx is free, hypertrophied posterior ends of the inferior turbinates are visible. The vault of the nasal pharynx is without pathological changes, the choanae are free, the pharyngeal tonsil is not enlarged, the mouths of the auditory tubes are not changed, the tubal tonsils are not enlarged. Laryngeal part of the pharynx (hypopharyngoscopy): the lingual tonsil is not enlarged, the vallecules are without pathological changes, the pyriform sinuses are free.

3. Larynx - Sonorous voice, calm, rhythmic breathing, not disturbed; On external examination, the condition of the laryngeal cartilage is without pathological changes, displaceable, the symptom of crepitus is positive. Indirect laryngoscopy - the outer ring of the larynx is not changed. The epiglottis is deployed in the form of a sheet covering the anterior parts of the vocal folds. The vocal folds are white, with full mobility in the posterior third.

Right ear: the auricle is externally without pathological changes, regular in shape, painless upon palpation and pressing on the tragus. Percussion of the mastoid area is painless. The external auditory canal is of normal width, there is a slight exostosis on the anterior-inferior wall of the external auditory canal. Eardrum - with all identification points, gray. No pathological discharge or membrane perforations were detected.

Left ear: the auricle is externally without pathological changes, regular in shape, painless on palpation. Percussion of the mastoid area is painless. The external auditory canal is of normal width. Eardrum - with all identification points, gray. Without pathological discharge, no perforations of the membrane were detected.

The examination begins with the diseased organ; in case of ear pathology, the examination begins with a healthy ear; if there are no complaints, the examination begins with the nose, then the pharynx, larynx, and ears are examined.

1) External inspection face, neck, ears (behind the ear area) - assess skin color, shape of nose, ears, larynx.

2)Palpation facial walls of the paranasal sinuses, mastoid processes, laryngeal cartilages, lymph nodes (premandibular and submandibular, cervical and parotid).

4)Examination of ENT organs:

A) anterior rhinoscopy: color of the nasal mucosa, volume of the nasal turbinates, shape of the nasal septum, content of the nasal passages

(example of a norm description: The shape of the nose is not changed. Nasal breathing is free. The sense of smell is not impaired. The vestibule of the nose is free. Nasal septum in the midline. The nasal turbinates are not enlarged. The nasal passages are free. The mucous membrane is pink, moist. Discharge is moderate, mucous).

b) pharyngoscopy: color, moisture of the oral mucosa, oropharynx, condition of the gums, teeth, tongue, excretory ducts of the salivary glands, hard palate, condition of the palatine tonsils: contents of lacunae, presence of adhesions, degree of mobility of the soft palate

(example of a norm description: The mucous membrane is of normal color. Teeth sanitized. The tongue is clean and moist. Hard palate without features. The soft palate is not changed, it is mobile. The palatine tonsils are not enlarged (grade I). Gaps are free. The arches are pink and not fused to the tonsils. The posterior wall of the pharynx is not changed).

V) posterior rhinoscopy performed by the teacher: the nasopharyngeal cavity, choanae, posterior ends of the nasal conchae, the condition of the pharyngeal and tubal tonsils, the mouths of the auditory tubes

(example of a norm description the choanae, the mouths of the eustachian tubes and the fornix are free. Vomer on the midline).

G) indirect laryngoscopy conducted by the teacher: color,
moisture of the mucous membrane of the larynx and hypopharynx, condition
pyriform fossae, lingual tonsil, epiglottis, color, humidity
vestibular and vocal folds, shape of the glottis, condition
subglottic space

(example of a norm description: breathing freely. Voice
saved, not changed. The pyriform sinuses are free. Epiglottis
usual form. The aryepiglottic folds are contoured. Didn't scoop
changed, mobile, interarytenoid space is free.
The vestibular and vocal folds are not changed, and their mobility is not limited. During phonation, the vocal folds close along the midline. The subglottic space is free).

d) Otoscopy: condition of the skin of the external auditory canal, its
width, color of the eardrum, presence and location of perforation, its
identifying elements of the membrane (handle, light reflex, folds,
short process of the malleus);

(example of a norm description: the skin of the mastoid processes is not changed, palpation and percussion are painless. The external auditory canals are free. The eardrum is pearl-colored, identification points are well defined).

AKUMETRY

VESTIBULOMETRY:

Spontaneous nystagmus

Pressor nystagmus

Post-rotational nystagmus

O.R. (buildings I, II, III st.)

V.R. (0, I, II, III st.)

MedElement offers comprehensive solutions for medical practice management: from patient registration to financial accounting.

The automation system "Electronic clinic MedElement" is based on the use of cloud technologies. The cloud system works over the Internet, and connecting a clinic to the system is little more complicated than creating an email account. The system does not require any programs other than a web browser to operate.


Electronic office of an otorhinolaryngologist


For ease of use, electronic offices of doctors of various specialties have been created in the MedElement system.

Main features of the otorhinolaryngologist’s electronic office:

  • Appointment scheduling management - electronic appointment calendar.
  • Reducing paperwork - electronic medical records of patients.
  • Entering reception data in a few mouse clicks - convenient data entry templates.
  • Specialized templates for an objective examination by an otolaryngologist (nose, sinus areas, nasopharynx, rhinoscopy, oral cavity, tonsils, larynx, pharynx, laryngoscopy, auricles, nerves).
  • Creation of your own text templates for examination, diagnoses, directions, appointments, recommendations.
  • Interpretation of laboratory results.
  • Archive of instrumental research results (attaching images and files to the medical history).
  • Printing of admission information in the form of standard forms.


What our clients say

Director of ENT centers "Sezim"Elza Alikhanovna Makhambetova:
The system makes the workload of each doctor transparent

“First of all, I would like to note the orderliness of the registrar’s work. The patient registration system for a month in advance is carried out individually for each doctor. Electronic archiving of patient visits is carried out. There is a good opportunity to use electronic mailings.
The resulting database saves the work of the registrar and the doctor on entering data and issuing statements for the patient. The problem of paper routine work has been solved.

Doctors have access to control the entire process of patient movement in the clinic, including payment and testing.

Submitting detailed reports on all desired indicators is very convenient for summarizing the work of a day or month. The system makes the workload of each doctor transparent, helps to track the cyclical nature of patients, the level of decline or rise in visits to our clinic.

Another version of the template (form) for examination by a therapist:

Examination by a therapist ​

Date of inspection: ______________________
Full name patient:_______________________________________________________________
Date of birth:____________________________
Complaints for pain behind the sternum, in the region of the heart, shortness of breath, rapid heartbeat, interruptions in heart function, swelling of the lower extremities, face, headache, dizziness, noise in the head, in the ears_____________________________________________________________________________

_
_______________________________________________________________________________

History of the disease:___________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_____________________________________________________________________________

Information about diseases, injuries, operations (HIV, hepatitis, syphilis, tuberculosis, epilepsy, diabetes, etc.): ___________________________________________________________________

Allergy history: not burdened, burdened________________________________
_______________________________________________________________________________

The general condition is satisfactory, relatively satisfactory, moderate, severe. Body position active, passive, forced
Body type: asthenic, normosthenic, hypersthenic_____________________
Height__________cm, weight__________kg, BMI____________(weight, kg/height, m²)
Body temperature: ________°C

Skin: pale color, pale pink, marbled, icteric, redness,
hyperemia, cyanosis, acrocyanosis, bronze, earthy, pigmentation_____________________
_______________________________________________________________________________
Skin moist, dry______________________________________________________________
Rash, scars, stretch marks, scratches, abrasions, spider veins, hemorrhages, swelling ________________________________________________________________________________

Oral mucosa: pink, hyperemia__________________________________________

Conjunctiva: pale pink, hyperemic, icteric, white-porcelain, edematous,
the surface is smooth, loosened_________________________________________________________

Subcutaneous fat fiber expressed excessively, sparingly, moderately.

Subcutaneous lymph nodes: not palpable, not enlarged, enlarged__________
_______________________________________________________________________________

Cardiovascular system. The tones are clear, loud, muffled, dull, rhythmic, arrhythmic, extrasystole. Murmurs: none, systolic (functional, organic), localized at the apex, including Botkin’s, above the sternum, to the right of the sternum ________________
_______________________________________________________________________________
Blood pressure ________ and ________ mmHg. Heart rate ________ per minute.

Respiratory system. Dyspnea is absent, inspiratory, expiratory, occurs when _____________________________________________________. Respiratory rate: ________ per 1 minute. Percussion sound is clear, pulmonary, dull, shortened, tympanic, boxed, metallic ___________________________
____________________________. Borders of the lungs: unilateral, bilateral prolapse, upward displacement of the lower borders ______________________________ In the lungs, during auscultation, breathing is vesicular, hard, weakened on the left, right, in the upper, lower sections, along the anterior, posterior, lateral surface___________________________. No wheezing, single, multiple, small-medium-large bubbling, dry, wet, whistling, crepitating, stagnant in nature on the left, right, on the front, back, side surface, in the upper, middle, lower sections _____________________
_________________________________. Sputum_____________________________________.

Digestive system. Bad breath _____________________________________. Tongue is moist, dry, clean, coated __________________________________________
The abdomen ____ is enlarged due to fatty tissue, edema, hernial protrusions ___________________________________________________________, soft, painless, painful on palpation ____________________________________________________________
Symptom of peritoneal irritation yes or no___________________________________________
The liver along the edge of the costal arch is enlarged___________________________________________,
____painful, dense, soft, smooth surface, lumpy _____________________
_______________________________________________________________________________
The spleen is ____enlarged_______________________________________, ____painful. Peristalsis ____disturbed _________________________________________________.
Defecation ______ once a day/week, painless, painful, stool is formed, liquid, brown, without mucus and blood ____________________________
____________________________________________________________________________

Urinary system. Symptom of tapping on the lower back: negative, positive on the left, right, on both sides. Urination 4-6 times a day, painless, painful, frequent, infrequent, nocturia, oliguria, anuria, light-straw-colored urine________________________________________________________________
_______________________________________________________________________________
Diagnosis:_______________________________________________________________________
_______________________________________________________________________________
______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

The diagnosis was established on the basis of information obtained during questioning of the patient, data from the medical history and illness, results of a physical examination, results of instrumental and laboratory tests.

Survey plan(consultations of specialists, ECG, ultrasound, FG, OAM, UBC, blood glucose, biochemical blood test): _____________________________________________
_______________________________________________________________________________

Treatment plan:__________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________

Signature_______________________Full name

For the full version of the document, see the attachment to the message