Form 025 for outpatient medical card. Patient's outpatient card: description, form, sample and extract

Outpatient card patient form 025 y - this 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 for the implementation of the treatment process in 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 Order No. 834n of the Ministry of Health, 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 on the compulsory medical insurance policy, the 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) – repository of operational data

Operational data includes all information that is received in the process of treating a patient, starting from the initial visit to a specialist. The map reflects the results of inspections, 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. Attached are the results of laboratory and functional methods research.

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. This conclusion is written by the 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.

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:

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:

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 ______________________

page 4 f. N 025/у

25. Medical observation over time:

page 5 f. N 025/у

page 6 f. N 025/у

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 on surgical interventions performed in outpatient

conditions

32. Sheet for recording radiation doses during x-ray examinations

page 12 f. N 025/у

33. Results of functional research methods:

page 13 f. N 025/у

34. Results of laboratory research methods.

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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 units 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 entered 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, enter the date of initial filling Cards.
Points 2 - 6 Cards are filled out based on the information contained in the patient’s identity document.
11.2. Clause 7 includes the series and number of the mandatory insurance policy health insurance, paragraph 8 - insurance number of the 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 in military units, institutions, military educational institutions that 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-line 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 the personnel of self-defense groups of facility and emergency teams of local air defense, as well as members of the families of deceased workers of hospitals and clinics 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 change of 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 indicates information about hospitalizations carried out, paragraph 31 - information about hospitalizations carried out surgical interventions, in paragraph 32 - information about the radiation doses received during x-ray studies.
11.19. On the pages corresponding to paragraphs 33 and 34, the results of functional and laboratory tests 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 a patient, a post-mortem epicrisis is drawn up, which reflects all the diseases, injuries, operations suffered, and a post-mortem final rubricated (divided into sections) diagnosis is issued; the series, number and date of issue of the registration form are indicated, and all causes of death recorded in it are also indicated.

You can purchase separately in our online store.

Form 025/у 04 was put into circulation in 2004. The form was developed by the Ministry of Health. Approval document – ​​Order number 255. Used medical card outpatient form 025/у 04 by institutions providing outpatient care (without providing a bed).

Form 025/у 04 is filled out during the patient’s initial visit to the institution or when visiting the home to provide medical services. One copy of the card is created for one patient in one institution. If a patient is seen by several specialists, they use the same document to keep records. Duplication of primary documentation would inevitably introduce confusion into the medical history and complicate treatment.

Outpatient card form 025/у 04 can be used by any medical outpatient organizations, regardless of location or specialization. The form is used by FAPs and health centers. The location of the form is the clinic reception. Here you can fill in the information on the title page.

Medical record form 025/у 04 is a landscape-type card, including a title page and internal pages for entering information. When printing, the form is made in full accordance with the form. Changes to an existing document are not permitted.

Card form 025/у 04 contains important personal information about the patient. The document includes not only basic passport data, but also telephone numbers that allow you to contact the patient, and information about the place of work. The insurance policy number and SNILS must be entered. For people who have any benefits, you must also enter the benefit code. If there is a disability, the corresponding column is filled in. Form 025/у 04 also includes information about a change of address and place of work.

For medical institution a medical card (form 025/у 04) is the main document of a citizen receiving outpatient services. The form contains up-to-date information about the main diagnosed diseases of the patient. Information about the presence of existing diseases that are subject to dispensary observation is entered in the appropriate columns. This is an important resource for the attending physician.

Information about such patient parameters as blood type, Rh factor and drug intolerance is also important. This data plays main role when providing certain types of emergency assistance, surgical interventions.

The map contains loose leaves that describe the dynamics of the disease. All visits or services provided at home are recorded. The form also records cases of issuance of certificates of incapacity for work. During treatment, the patient may require hospitalization in an inpatient clinic. In this case, form 025/у 04 is transferred to the hospital for the duration of treatment and is added to the main medical record of the patient in the hospital.

Buy an outpatient medical card form 025/у 04

You can buy a patient’s medical card form 025 from 04 in Moscow at the City Blank printing house. We can produce outpatient card form 025/у 04 in a single copy or print a batch of the required size. A certain number of forms may be in stock. Check availability with managers.

You can pick up your medical card in person when you visit our offices. You can order courier delivery to your door. We also cooperate with largest companies carriers, and we can send the purchase to any region of Russia. Postal delivery to the desired location is possible.

Doctors do not always assess the importance of the rules for maintaining primary medical documentation; they do not pay attention to the basic registration and operational medical, legal documents used in the work, in particular, on whether the registration form 025/у - outpatient card is filled out correctly.

Form N 025/у - the main accounting document of a medical organization providing outpatient care to the adult population

To correctly prepare, record and store an outpatient card, you need to know the requirements and rules for maintaining primary medical records.

The material contains sample forms and ready-made forms for downloading.

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The main thing in the material of the article

An outpatient medical record must be filled out taking into account the existing rules and requirements for its completion; according to the instructions for maintaining the new form N 025/u, long-term and operational information about the patient must be entered into the medical record.

Accounting form 025/у: maintenance regulations

1. Description of the patient's condition, treatment and diagnostic measures, treatment outcomes and other necessary information.
2. Maintaining the chronology of events that influence clinical and organizational decisions.
3. Reflection in medical documentation of social, physical, physiological and other factors that may affect the patient and the course of the pathological process.
4. Understanding and compliance by the attending physician with the legal aspects of his activities, responsibilities and significance correct design;
5. Recommendations for the patient upon completion of the examination and completion of treatment.

Requirements for obtaining an outpatient card

• reflect the patient’s complaints, medical history, results objective examination, clinical (verified) diagnosis, prescribed diagnostic and therapeutic measures, necessary consultations, as well as all information on monitoring the patient for prehospital stage(prophylactic examinations, results of dispensary observation, visits to an emergency medical service station, etc.);
• identify and record risk factors that may aggravate the severity of the disease and affect its outcome;
• present objective, reasonable information to ensure “protection” of medical personnel from the possibility of a complaint or lawsuit;
• record the date of each entry;
• Each entry must be signed by a doctor (with full name decrypted).
• stipulate any changes, additions, indicating the date of the changes and the signature of the doctor;
• do not allow records that are not related to the provision of medical care to this patient;
• entries in the patient's chart must be consistent, logical and thoughtful;
• promptly refer the patient to a meeting of the medical commission and a medical and social examination;
• devote Special attention records when providing emergency medical care and in complex diagnostic cases;
• justify the prescribed treatment for the preferential category of patients;
• provide for preferential categories patients to issue prescriptions in 3 copies (one is pasted into the patient’s outpatient card).

What are the requirements for filling out form 025/у?

What is regulated in form 025/у the procedure for keeping records in terms of collecting complaints, anamnesis, objective status, examination plan, treatment plan, as well as making records of prescribed medications according to international generic name, besides the order?

In addition to the above procedure, the following legal regulations must be followed.

What information should be in an outpatient's medical record?

IN the worksheet provides information about what information needs to be recorded in the card, how to fill them out and when they need to be entered.

Prescribing and prescribing medications

The procedure for prescribing and prescribing medications was approved by Order of the Ministry of Health of Russia dated December 20, 2012 N 1175n.

According to clause 5 of the Procedure, information about the prescribed and discharged medicinal product (name of the medicinal product, single dose, method and frequency of administration or administration, course duration, rationale for prescribing the medicinal product) is indicated in the outpatient patient’s medical record.

Fact of issuing a prescription for a drug legal representative recorded in the patient's medical outpatient record.

Based on clause 3 of the Procedure, the prescription and prescription of medications is carried out by a medical professional using the international nonproprietary name, and in its absence, the generic name.

In the absence of an international nonproprietary name and generic name of a medicinal product, the medicinal product is prescribed and prescribed by a medical professional under its trade name.

It is allowed to record the names of medicinal products in Latin.

When prescribing narcotic and psychotropic drugs of lists II and III of the List, the dose of which exceeds the highest single dose, the medical worker writes the dose of this drug in words and puts an exclamation point (clause 14 of the Procedure).

Regulations for prescribing and prescribing NS and PV

The procedure for prescribing NS and PV has been changed. A combination of NS with an opioid receptor antagonist has been added to section I of the list of drugs that are subject to subject-quantitative recording. How to prescribe medications now, read the instructions in the magazine "Deputy Chief Physician".

In the article you can also see tables on forms for NS and PV and the maximum permissible amount of NS and PV per prescription.

The method of use of the drug is indicated indicating the dose, frequency, time of administration relative to sleep (morning, at night) and its duration, and for drugs that interact with food - the time of their use relative to meals (before meals, during meals, after food) (clause 17 of the Procedure).

In the cases specified in clause 25 of the Procedure, the prescription of medications is recorded in the patient’s medical documents and certified by the signature of the medical worker and the head of the department (responsible doctor on duty or other authorized person).

If a medicinal product is prescribed by decision of a medical commission, the decision of the medical commission is recorded in the patient’s medical documents (clause 27 of the Procedure).

Thus, when prescribing medications, the patient’s medical record indicates:

1. Name of the medicinal product (international non-proprietary, group or trade; names of medicinal products can be written in Latin).
2. Method of administration (dose, frequency, time of use relative to sleep (morning, at night), duration of use, time of use relative to meals (before meals, during meals, after meals).
3. Rationale for prescribing the drug.
4. The fact that a prescription for a drug was issued to a legal representative (if such a fact exists).
5. The decision of the medical commission to prescribe the drug (in certain cases).
6. Signature of the medical professional who prescribed the drug.
7. Signature of the head of the department, the responsible doctor on duty or another authorized person (in certain cases).
8. Signature of the secretary of the medical commission (in certain cases).

How to provide medical documentation to a patient. New rules

We will explain how to implement the law in practice during an outpatient appointment and in hospital departments.

Instructions

Form N 025/у - the main registration medical document providing medical care on an outpatient basis to the adult population

Differences: outpatient card form 025/у-04 and 025/у

Form No. 025/u has significant differences from its predecessor - form No. 025/-04 “Medical record of an outpatient.” It is more detailed, that is, when filling it out you must indicate large quantity information about the patient.

However, precisely thanks to its detail new form can tell doctors what information about the patient in mandatory must be included in the primary medical documents.

The procedure for filling out registration form N 025/у

(approved by order of the Ministry of Health Russian Federation dated December 15, 2014 N 834n)

1. Registration form N 025/у (hereinafter referred to as the Card) is the main registration medical document of a medical organization (other organization) providing medical care on an outpatient basis to the adult population (hereinafter referred to as a medical organization).

2. The card is filled out for each patient who seeks medical care in an outpatient setting for the first time. For each patient in a medical organization or its structural unit providing medical care on an outpatient basis, one Card is filled out, regardless of how many doctors provide treatment.

3. Cards are not maintained for patients seeking medical care on an outpatient basis in specialized medical organizations or their structural divisions in the fields of oncology, phthisiology, psychiatry, psychiatry-narcology, dermatology, dentistry and orthodontics, who fill out their registration forms.

4. The card is filled out by doctors; medical workers with secondary vocational education who conduct independent consultations 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 of citizens entitled to receive a set of social services are marked with the letter “L” (next to the Card number).

6. The title page of the Card is filled out at the registry of the medical organization when the patient first seeks medical help.

7. On the title page of the Card, the full name of the medical organization is indicated in accordance with its constituent documents, the OGRN code, and the Card number is indicated - the individual Card registration number established by the medical organization.

8. The Card reflects the nature of the course of the disease (injury, poisoning), as well as all diagnostic and therapeutic measures carried out by the attending physician, recorded in their sequence.

9. The card is filled out for each patient visit. The Map is maintained by filling out the relevant sections.

10. Entries are made in Russian, accurately, without abbreviations, all necessary corrections in the Card are made immediately, confirmed by the signature of the doctor filling out the Card. It is allowed to record the names of medicinal products in Latin.

11. When filling out the Card

11.1. In column 1, enter the date of initial filling of the Card. Points 2 - 6 Cards are filled out based on the information contained in the patient’s identification document.

11.2. Clause 7 includes the series and number of the compulsory medical insurance policy, clause 8 - the insurance number of the individual personal account (SNILS), clause 9 - the name of the medical insurance organization.

11.3. Line 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" - 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 Federal Law dated January 12, 1995 N 5-FZ “On Veterans”;
• “4” - military personnel who served in military units, institutions, military educational institutions that 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 orders or medals USSR 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-line 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” - family members of deceased (deceased) war invalids, participants in the Great Patriotic War and combat veterans, family members of persons killed in the Great Patriotic War from among the personnel of self-defense groups of facility and emergency teams of local air defense, as well as family members of deceased workers hospitals and clinics of the city of Leningrad;
• "8" - disabled people;
• "9" - disabled children.

11.4. Line 11 indicates the patient’s identification document.

11.5. “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, for peptic ulcer disease by a general practitioner and a surgeon), each such disease is indicated once by the medical specialist who first identified dispensary observation. If a patient is observed for several etiologically unrelated diseases by one or more medical specialists, then each of the diseases is noted in paragraph 12 .

11.6. In the “Marital status” section, a record is made of whether the patient is registered married or unmarried, based on the information contained in the patient’s identity document. If there is no information, "unknown" is indicated.

11.7. “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. 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 or equivalent service;
• In the position "pensioner(s)" indicate unemployed persons those receiving a labor (old age, disability, survivor) or social pension;
• The position “student(s)” indicates students studying in educational organizations;
• The position “not working” indicates able-bodied citizens who do not have a job or income, are registered with the employment service in order to find suitable work, are looking for work and are ready to start work;
• 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 column 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. 20 - all first or repeatedly established final (refined) diagnoses and the doctor’s full name are indicated.

11.13. In points 21 and 22, the blood type and Rh factor are noted, and in point 23 - allergic reactions that the patient had previously.

11.14. In "24" records of medical specialists are made by filling out the appropriate lines.

11.15. Point 25 is used to record the patient’s condition during observation over time.

11.16. “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 for whom dispensary observation is carried out is recorded in section 29.

11.18. In 30 information about hospitalizations performed is indicated, in 31 - information about surgical interventions performed, in 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 tests are pasted.

11.20. 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 departure, the epicrisis is sent to the medical organization at the place of medical observation of the patient or handed over to the patient.

In the event of the patient’s death, a post-mortem epicrisis is drawn up, which reflects all the diseases, injuries, operations suffered, and a post-mortem final rubricated (divided into sections) diagnosis is issued; the series, number and date of issue of the registration form “Medical Death Certificate” are indicated, and all causes of death recorded in it are also indicated.