List of documents for the passage of MSE. What is a referral to ITU? What medical and preventive organizations issue it and how to get it? Medical documentation form 088 y 06

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1 MINISTRY OF HEALTH AND SOCIAL DEVELOPMENT OF THE RUSSIAN FEDERATION ORDER of January 31, 2007 N 77 On approval of the form for referral for medical and social examination by an organization providing medical and preventive care (as amended on October 28, 2009) Document with amendments made by: order of the Ministry of Health and Social Development of Russia dated October 28, 2009 N 853n (Rossiyskaya gazeta, N 232,) (entered into force on January 1, 2010). In accordance with the Decree of the Government of the Russian Federation of February 20, 2006 N 95 "On the procedure and conditions for recognizing a person as disabled" (Collected Legislation of the Russian Federation, 2006, N 9, Art. 1018) I order: for a medical and social examination by an organization providing medical and preventive care" according to the appendix. Minister M. Zurabov Registered with the Ministry of Justice of the Russian Federation on March 12, 2007, registration N 9089 Appendix. Form N 088 / y-06. Referral for medical and social examination by an organization providing medical and

2 preventive care Appendix to the order of the Ministry of Health and Social Development of the Russian Federation of January 31, 2007 N 77 (as amended, put into effect on January 1, 2010 by order of the Ministry of Health and Social Development of Russia of October 28, 2009 N 853n, - see the previous edition) Medical documentation Form N 088 / y-06 Ministry of Health and Social Development of the Russian Federation (name and address of the organization providing medical and preventive care) REFERRAL FOR MEDICAL AND SOCIAL EXAMINATION BY THE ORGANIZATION PROVIDING THERAPEUTIC AND PREVENTIVE CARE Date of issue " " 20*

3 1. Surname, name, patronymic of the citizen sent for medical and social examination (hereinafter referred to as the citizen): 2. Date of birth: 3. Gender: 4. Surname, and my name, patronymic of the legal representative of the citizen (to be filled in if there is a representative) : legal 5. Address of the place of residence of the Citizen (in the absence of a place of residence, the address of stay, actual residence in the territory of the Russian Federation is indicated): 7. Excluded 8. The degree of loss of professional ability to work in percent:

4 (to be filled in upon re-sending) 9. Sent initially, re-sent (underline as necessary). 10. Who works at the time of sending for a medical and social examination (indicate the position, profession, specialty, qualifications and length of service in the specified position, profession, specialty, qualifications; for non-working citizens, make an entry: "does not work") 11. Name and address of the organization in which the citizen works: 12. Conditions and nature of the work performed: 13. Main profession (specialty): 14. Qualification in the main profession (class, category, category, rank):

5 15. Name and address of educational institution: 16. Group, class, course (underline to be indicated): 17. Profession (specialty) for which training is provided: 18. Observed in organizations providing medical and preventive care since a year. 19. History of the disease (beginning, development, course, frequency and duration of exacerbations, carried out medical and rehabilitation and rehabilitation measures and their effectiveness):

6 (it is described in detail during the primary referral; during the second referral, the dynamics for the period between examinations is reflected, new cases of diseases detected during this period that led to persistent violations of the body's functions are described in detail) operations, diseases for which heredity is aggravated, in addition, in relation to the child, it is indicated how the pregnancy and childbirth proceeded in the mother, the timing of the formation of psychomotor skills, self-service, cognitive-playing activities, skills of neatness and self-care, how early development proceeded (by age, lagging, ahead): (filled in during the primary referral) 21. Frequency and duration of temporary disability (information for the last 12 months): N Date (day, month, year) of the beginning of temporary disability incapacity for work Number of days (months and days) incapacity for work Diagnosis

7 22. The results of the measures taken for medical rehabilitation in accordance with the individual program for the rehabilitation of a disabled person (to be filled in upon re-referral, specific types of rehabilitation therapy, reconstructive surgery, sanatorium treatment, technical means of medical rehabilitation, including prosthetics and orthotics, as well as the terms, to which they were provided; lists the functions of the body that could be compensated or restored in whole or in part, or a note is made that there are no positive results): other specialties):

8 24. Results of additional research methods (the results of laboratory, X-ray, endoscopic, ultrasound, psychological, functional and other types of research are indicated): 25. Body weight (kg), height (m), body mass index. 26. Assessment of physical development: normal, deviation (underweight, overweight, short stature, high stature) (underline as appropriate).

9 27. Evaluation of psychophysiological endurance: norm, deviation (underline as necessary). 28. Evaluation of emotional stability: norm, deviation (underline as necessary). 29. Diagnosis when referring to a medical and social examination: a) underlying disease code according to the ICD: b) underlying disease: c) concomitant diseases: d) complications: 30. Clinical prognosis: favorable, relatively favorable, doubtful (uncertain), unfavorable ( Underline whatever applicable).

10 31. Rehabilitation potential: high, satisfactory, low (underline as appropriate). 32. Rehabilitation prognosis: favorable, relatively favorable, doubtful (uncertain), unfavorable (underline as appropriate). 33. The purpose of sending for a medical and social examination (underline as appropriate): to establish disability, the degree of loss of professional ability to work in percent, to develop (correct) an individual rehabilitation program for a disabled person (disabled child), a rehabilitation program for a victim of an accident at work and an occupational disease , for another (specify): 34. Recommended measures for medical rehabilitation for the formation or correction of an individual rehabilitation program for a disabled person (disabled child), a rehabilitation program for a victim of an accident at work and an occupational disease:

11 (specific types of rehabilitation therapy are indicated (including drug provision in the treatment of a disease that caused disability), reconstructive surgery (including drug provision in the treatment of a disease that caused disability), technical means of medical rehabilitation, including prosthetics and orthotics, a conclusion on the sanatorium - spa treatment with a prescription for the profile, frequency, duration and season of recommended treatment, the need for special medical care for persons injured as a result of accidents at work and occupational diseases, the need for medicines for the treatment of the consequences of accidents at work and occupational diseases, other types of medical rehabilitation) Chairman of the medical commission: (signature) (signature transcript) Members of the medical commission: (signature) (signature transcript) (signature) (signature transcript) (signature) (signature transcript) M.P. Cutting line

12 To be returned to the organization providing medical and preventive care that issued the referral for medical and social examination Return coupon (name of the federal state institution of medical and social examination and its address) social examination 4. Diagnosis of the federal state institution of medical and social examination: a) code of the underlying disease according to the ICD:

13 c) concomitant diseases: c**) complications: 5. Types of disorders of body functions and their severity (according to the classifications approved by the order of the Ministry of Health and Social Development of Russia of August 22, 2005 N 535 (registered in the Ministry of Justice of Russia on September 13, 2005 N 6998): 6. Limitations of the main categories of life activity and the degree of their severity (according to the classifications and criteria approved by the order of the Ministry of Health and Social Development of Russia dated August 22, 2005 N 535):

14 7. Decision of the federal state institution of medical and social expertise: disability of the first, second, third groups was established, in the category "disabled child" (underline as necessary); cause of disability: degree of loss of professional ability to work in percent: date of re-examination: recommendations for medical rehabilitation: recommendations for professional, social, psychological and pedagogical rehabilitation:

15 8. Reasons for refusal to establish disability: 9. Date of sending the return coupon: " " 20. Head of the federal state institution of medical and social expertise (signature) (signature decoding) M.P. * Not later than one month from the date of issue, this referral can be submitted by a citizen (his legal representative) to the branch of the main bureau of medical and social expertise - the bureau of medical and social expertise. ** The numbering corresponds to the original. - Database manufacturer's note.

16 The version of the document, taking into account changes and additions, was prepared by Kodeks JSC

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LPU stamp

Approved by Order of the Ministry of Health
and social development of the Russian Federation
dated January 31, 2007 N 77
Medical documentation
Form N 088/u-06​

DIRECTION
for medical and social expertise by an organization providing
medical and preventive care

Date of issue "______" ___________________________ 20_____
1. Surname, name, patronymic of a citizen sent for a medical and social examination (hereinafter referred to as a citizen): Ivanov Viktor Alexandrovich
2. Date of birth: 07/11/1948.
3. Gender: male
4. Surname, name, patronymic of the legal representative of the citizen (to be filled in if there is a legal representative): _________________________________________________________________
5. Address of the place of residence of a citizen (in the absence of a place of residence, the address of stay, actual residence on the territory of the Russian Federation is indicated): Russian Federation, 000000, N-sky region, N-sky district, N-sky, st. Gulagskaya, d. 1, GBUSONO "N-sky PNI"
6. Not a disabled person, disabled person first, second, third groups, category "disabled child" (underline as appropriate).
7. The degree of loss of professional ability to work in percent: __________________________
(to be completed upon resubmission)
8. Sent first, re(Underline whatever applicable).
9. What job at the time of referral for medical and social examination: does not work
(indicate the position, profession, specialty, qualifications and length of service in the specified position, profession, specialty, qualifications; for non-working citizens, make an entry: “does not work”)
10. Name and address of the organization in which the citizen works: does not work
11. Conditions and nature of the work performed: does not work
12. Main profession (specialty): driver, tractor driver
13. Qualification in the main profession (class, category, category, rank): No
14. Name and address of the educational institution: No
15. Group, class, course (underline to indicate): No
16. Profession (specialty) for which training is provided: No
17. Observed in organizations providing medical and preventive care, with 2005 of the year.
18. History of the disease (beginning, development, course, frequency and duration of exacerbations, carried out medical, recreational and rehabilitation measures and their effectiveness):

In 2005, he suffered a traumatic brain injury, was treated in a hospital with a diagnosis of brain contusion. For 20 years, he abused alcohol, long binges with severe withdrawal symptoms, for which he was repeatedly treated in a hospital. The mental state changed - he began to leave home for a long time, wandered, got lost. He became whiny, sentimental, lost his hygiene skills, spent a lot of time in bed, became indifferent to relatives. At the same time, he expressed unrealistic plans for the future, which he immediately forgot about. In connection with the growth of the emotional-volitional defect and behavioral disorders, he was repeatedly hospitalized in the PND of the city of N-ska. The first medical and social examination was carried out on November 18, 2013. For the period between ITU mental state with negative dynamics. The last hospitalization in PND No. 1 of N-ska from 03.04.2014 On June 20, 2014, he was discharged with a diagnosis of “Organic personality disorder due to mixed diseases (TBI, intoxication) with cognitive impairment. Astheno-neurotic syndrome". In PND No. 1, N-ska received treatment: phenibut, vinpocetine, pentoxifylline, omarone, during the treatment the emotional background somewhat leveled off. After being discharged on social grounds, he was transferred to the N-sky PNI. In the boarding school he is passive, spends time in bed, does not take care of himself, does not go to the dining room himself, washes with a reminder. He takes medication under the supervision of staff: piracetam, cinnarizine, betahistine, thioryl, combilipen, cavinton, phenazepam, azafen. Relatives of the patient do not visit. Needs outside help and care.

________________________________________________________________________________________
(it is described in detail during the primary referral; during the second referral, the dynamics for the period between examinations is reflected; new cases of diseases detected during this period that led to persistent impairment of body functions are described in detail)

19. History of life (diseases, injuries, poisonings, operations, diseases suffered in the past, for which heredity is burdened, are listed, additionally, in relation to the child, it is indicated how the mother's pregnancy and childbirth proceeded, the timing of the formation of psychomotor skills, self-care, cognitive and gaming activities, neatness and self-care skills, how early development proceeded (by age, lagging behind, ahead of time)):

Born in the city of N-sk. Younger of two brothers. Heredity is not psychopathologically burdened. He grew up, developed according to his age, attended preschool institutions. I went to school from the age of 7, graduated from 10 classes. Served in the army. He graduated from driving courses, worked as a bulldozer, tractor driver, driver. He was married twice and has an adult son. Lived with an elderly mother. Family ties are lost. Retiree. Socially maladjusted. On June 20, 2014, he entered the N-sky PNI for residence by transfer from PND No. 1 of the city of N-ska.
_______________________________________________________________________________________
(to be filled in at the primary referral)

20. Frequency and duration of temporary disability (information for the last 12 months):
№
Date (day, month, year) of the start of temporary disability
Date (day, month, year) of the end of temporary disability
Number of days (months and days) of temporary disability
Diagnosis

21. The results of the measures taken for medical rehabilitation in accordance with the individual rehabilitation program for a disabled person (to be filled in upon re-referral, specific types of restorative therapy, reconstructive surgery, sanatorium-resort treatment, technical means of medical rehabilitation, including prosthetics and orthotics, as well as the terms in which they were provided; lists the functions of the body that could be compensated or restore in whole or in part, or a note is made that there are no positive results):

Measures of medical rehabilitation without a positive effect. He received treatment with nootropic and vasoactive drugs, vitamins, tranquilizers, antidepressants according to indications in various doses.

22. The state of a citizen when sent for a medical and social examination (complaints, examination data by the attending physician and doctors of other specialties are indicated):

Seen by a psychiatrist: the posture is hunched, moves independently, uncertainly, uses glasses. He dresses and eats on his own. Outwardly, somewhat unkempt. Consciousness is not clouded. Disoriented in place, in time, believes that now is 1948. In his own personality is oriented correctly. Contact is available. He misunderstands many questions and asks again. He interrupts the doctor, tries to tell how difficult life is for him, refers to his helplessness, complains that no one is treating him. Complains of general weakness, dizziness. Requires bed rest, then rudely refuses this opportunity. Emotionally unrestrained, easily affected. Irritated, when asked about his state of health, he answers with anger: “How can a sick person feel?!”. Intelligence, memory with a significant decrease. Thinking is slow in pace, viscous, unproductive. He finds words with difficulty, quickly exhausts himself in conversation. Volitional abilities are significantly weakened. In the department, he spends time in bed, refuses to go to the dining room, because he is afraid of getting lost, rudely refuses outside help: “bring food to the ward.” The mood background is reduced. She denies having suicidal thoughts. To his condition and the current situation is not critical. Active psychoproduction is not detected. Sleep, appetite are not disturbed. Physiological functions are controlled.
________________________________________________________________________________________
________________________________________________________________________________________

23. Results of additional research methods (the results of the conducted laboratory, radiological, endoscopic, ultrasound, psychological, functional and other types of studies are indicated):

UAC dated 10/23/14.:Hb=131g/l, WBC=5.7x109/l, ESR=5mm/h
OAM dated 06.11.14.:Ket=none, Glu=none, Lev=none
FG dated 11/18/14.: Lungs and heart are normal
ECG dated 10/31/14.: Sinus rhythm, normal ECG
Chest circumference 85 cm,waist circumference 80cm,hip circumference 87 cm.
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________

24. Body weight: 59 kg., height: 1,68 m., body mass index: 20,9 .

25. Assessment of physical development: normal, deviation (underweight, overweight, short stature, high stature) (underline as appropriate).

26. Evaluation of psychophysiological endurance: norm, deviation(Underline whatever applicable).

27. Assessment of emotional stability: norm, deviation(Underline whatever applicable).

28. Diagnosis when referring to a medical and social examination:

A) code of the underlying disease according to the ICD: F07.08

B) underlying disease: Severe organic personality disorder due to mixed diseases (TBI, intoxication) with cognitive impairment. Persistent social and labor maladaptation.

B) concomitant diseases:

Therapist: Chronic toxic (alcoholic) hepatitis in remission.

Neurologist: Dyscirculatory encephalopathy III stage.combined genesis.Astheno-neurotic syndrome.

Optometrist: Retinal angiopathy in both eyes.

D) complications: ________________________________________________________________________
________________________________________________________________________________________

29. Clinical prognosis: favorable, relatively favorable, doubtful

30. Rehabilitation potential: high, satisfactory, short(Underline whatever applicable).

31. Rehabilitation prognosis: favorable, relatively favorable, doubtful(indefinite), unfavorable (underline as appropriate).

32. Purpose of referral for medical and social examination (Underline whatever applicable): to establish disability , the degree of loss of professional ability to work in percent, for the development (correction) of an individual rehabilitation program for a disabled person (disabled child), programs for the rehabilitation of the victim as a result of an accident at work and an occupational disease, for another (specify): _______________________________________
________________________________________________________________________________________

33. Recommended measures for medical rehabilitation for the formation or correction of an individual rehabilitation program for a disabled person (disabled child), a rehabilitation program for a victim of an accident at work and an occupational disease:

1. Monitoring by a psychiatrist is constant.

2. Drug treatment: nootropics, vasoactive drugs, tranquilizers, antidepressants as indicated.

3. Rational occupational therapy for the development and maintenance of household skills for self-care.

(specific types of rehabilitation therapy are indicated (including drug provision in the treatment of a disease that caused disability), reconstructive surgery (including drug provision in the treatment of a disease that caused disability), technical means of medical rehabilitation, including prosthetics and orthotics, a conclusion on sanatorium spa treatment with a prescription for the profile, frequency, duration and season of recommended treatment, the need for special medical care for persons injured as a result of accidents at work and occupational diseases, the need for medicines for the treatment of the consequences of accidents at work and occupational diseases, others types of medical rehabilitation)​

Chairman of the medical commission:
Commission members:

The procedure of medical and social examination is obligatory for the establishment of disability. In the material of the article, we will consider the referral to the ITU (form 088u-06) - regulatory requirements and nuances of filling out, a sample of filling out the form of this document for epilepsy, criteria for assessing persistent disorders of body functions

In the material of the article, we will consider a new direction at the ITU (form 088y) - regulatory requirements and nuances of filling out, give a sample of filling out the form N088y-06 for epilepsy, and also describe the criteria for assessing persistent disorders of body functions used to make a decision on establishing a group for a person disability.

What to consider the subtleties when filling out this document? What features of the patient to pay attention to during the procedure for establishing disability?

↯ More articles in the journal

The main thing in the article

Before a patient is assigned a disability group, he will have to undergo a medical and social examination procedure, the referral for which is issued by the medical commission of the medical organization.

This direction is drawn up on the form of a new form. The document was also approved by the Ministry of Labor by order No. 578n/606n dated September 6, 2018.

From December 8, the Bureau of Medical and Social Expertise has the right not to accept outdated forms from patients.

Regulatory Requirements: Sample Form

Form 088y is issued in a medical institution. The completed document, together with the patient's written application, is submitted to the ITU bureau according to the disease profile.

If there are no papers in the package of documents submitted by the patient, he must submit them no later than 10 working days from the date of application.

Design features

Form No. 088u is issued in two copies - one is given to the patient in the hands, the second is filed into the outpatient card or into the medical history.

This measure is justified and even necessary, since the referral to the ITU contains all the information about the specialists who examined and treated the patient, as well as those responsible for his IHC or labor examination.

Item 23 of the form is filled in by the attending physician based on information from the medical history. To make a final decision on assigning a disability group to a patient, the commission must analyze not only the referral to the ITU, but also the relevant medical documentation.

The referral form is signed by the chairman of the medical commission of the medical institution and all its members. A stamp in the upper left corner of the institution with the name of the medical institution is not needed, since all the necessary information about it is already in the "header" of the document.

Medical expertise: 7 cases that baffled the deputies - see the article of the magazine "Deputy Chief Physician".

An example of filling out a direction

Consider the features of filling out the referral form to the ITU for a patient with epilepsy. In this case, the data of inspections are entered in the form N088у-06.

It is also necessary to indicate the frequency and nature of attacks and confirm this information with relevant medical reports.

If the patient has cognitive disorders, it is necessary to supplement the referral with data from a psychiatric examination. The main components of a referral for a medical and social examination for a patient with epilepsy:

• severity and frequency of epileptic seizures and their analogues (average number per year);
• persistent moderate or severe cognitive impairment (psycho-organic syndrome);
• presence of personality disorders.

The doctor in the direction indicates the impossibility of the patient to lead a full-fledged social life and the restriction of his life in standard situations (family, work, study, communication, movement).

In addition, the results of additional studies (EEG, MRI, CT, EchoEG, etc.), as well as experimental psychological examination, should be described in the form N088u-06.

In form No. 088y, the doctor indicates not only the clinical prognosis of the disease, but also the patient's rehabilitation potential (paragraphs 31, 32).

The main evidence of a favorable clinical prognosis is remission.

The following types are distinguished:

1. Incomplete - seizures stop, but paroxysmal activity persists on the EEG.
2. Complete - paroxysmal activity on the EEG is absent.

What documents are needed to determine the degree of loss of professional ability to work as a result of an accident or occupational disease, read in the Chief Physician System.

Properly selected drug therapy can achieve complete remission in about 80% of patients with epilepsy.

The following factors indicate an unfavorable prognosis:

• the form of the disease;
• development of drug resistance;
• the predominance of generalized, complex partial seizures of epilepsy;
• the presence of dysphoria and twilight disorders of consciousness;
• epileptic status;
• post-attack symptoms;
• tendency to serial attacks;
• the rapid growth of personality disorders and psycho-organic syndrome;
• irregularity or inadequacy of therapy;
• social maladjustment (frequent change of occupation, absence of a family, tendency to alcoholism, etc.).

Under the rehabilitation potential for epilepsy, one should understand the possibility of compensating for social insufficiency and disability that have formed as a consequence of the disease.

The concept of "rehabilitation potential" includes several aspects:

• biomedical;
• psychological;
• social.

Evaluation of the rehabilitation potential can say a lot about the rehabilitation prognosis for epilepsy.

Drugs prescribed for this disease should clearly correspond to the type of attack, other characteristics of the pathology, the sex of the patient, his weight, as well as his lifestyle and concomitant treatment.

If the prescribed monotherapy is ineffective, the doctor prescribes a combined treatment, based on the principles of rationality.

It lasts at least 9 months in patients who have attacks every day or every week, and one and a half to two years in patients with single attacks during the year.

Modern domestic and foreign standards for the treatment of epilepsy make it possible to make therapy more effective and significantly improve the quality of human life.

The rehabilitation prognosis is described in paragraph 33 of form 088y - here the doctor assesses the likelihood of achieving rehabilitation goals.

A favorable rehabilitation prognosis implies high chances of a complete restoration of the disturbed categories of the patient's vital activity, a relatively favorable one - their partial restoration with a decrease in the degree and stabilization of restrictions.

An unfavorable rehabilitation prognosis is the inability to even partially restore the categories of life activity disturbed by the disease.

In paragraph 34 of the referral to the ITU, it is necessary to describe the measures for medical rehabilitation, provide medical recommendations. All this is included in the individual program for the rehabilitation of the disabled (IPR).

What ITU evaluates

According to the results of the medical and social commission, a person receives the status of a disabled person. If we are talking about a minor citizen, then he is assigned the status of a disabled child.

When establishing disability, the following classifications are used:

1. The main types of persistent disorders of body functions, their severity.
2. The main categories of human life and the degree of severity of their limitations.

There are 4 degrees of severity of violations of body functions. The degrees are evaluated as a percentage (from 10 to 100% in 10% increments).

They are presented in the table below:

A person's disability is established taking into account his age characteristics. If a citizen is over 18 years old, disability is assigned in the following cases:

• restriction of II or III degree of severity of one of the main categories of human life activity or I degree of severity of restrictions of two or more categories of human life activity in various combinations.

What are the deadlines for appealing the decision of the examination

The complainant can file a complaint with a higher authority. In what terms it is possible to appeal against the decision of the ITU, how quickly the bureau should respond to requests, and in what cases it may not respond at all - find out the Chief Physician in the recommendation of the System.

For minors, disability is established in the following cases:

• II or more severity of persistent disorders of body functions (40-100%);
• restriction of any degree of severity of restrictions of any of the categories of human life, as a result of which the child needs social protection.

The table below describes which disability group is assigned based on the severity of persistent impairment of bodily functions:

Minors receive the status of a child with a disability if they have II, III or IV severity of persistent disorders of body functions (40-100%) resulting from injuries or defects.