Sample patient outpatient card. Electronic medical record of the patient: advantages of work, features of implementation and management

Appendix 8

to the Order

Ministry of Health

and social development

Russian Federation

dated November 22, 2004 N 255

INSTRUCTIONS

BY COMPLETING ACCOUNTING FORM N 025/U-04

"MEDICAL CARD OF AN OUTPATIENT PATIENT"

The “outpatient medical card” (hereinafter referred to as the Card) is the main primary medical document of a patient treated on an outpatient basis or at home, and is filled out for all patients when they first seek medical care at a given medical institution.

For each patient in the clinic, one Medical record is maintained, regardless of whether he is being treated by one or several doctors.

Cards are kept in all institutions providing outpatient care, general and specialized, urban and rural, including paramedic and obstetric stations (hereinafter - FAP), medical and paramedic health centers, Cards are in the registry on a precinct basis, Cards of citizens entitled to receive a set social services are marked with the letter “L”.

The title page of the Card is filled out at the reception of a medical institution when the patient first seeks medical help (consultation).

The title page of the Card contains the full name of the medical institution in accordance with the registration document and the OGRN code.

The Card number is entered - the individual Card registration number established by the medical institution.

Line 1 “Medical insurance organization” indicates the name of the insurance company that issued the compulsory medical insurance policy.

Line 2 contains the number of the compulsory medical insurance policy in accordance with the form of the submitted policy.

Line 3 contains the benefit code.

Line 4 contains the insurance number of the individual personal account (SNILS) of the citizen in the Pension Fund of the Russian Federation, which is formed in the Federal Register of persons entitled to state social assistance in the form of a set of social services (Federal Law of July 17, 1999 N 178-FZ "On state social assistance"; Collection of Legislation of the Russian Federation, 2004, No. 35, Art. 3607).

The citizen's last name, first name, patronymic, gender, date of birth, address of permanent residence in the Russian Federation are filled in in accordance with the identity document.

If a citizen does not have a permanent place of residence in the Russian Federation, the registration address at the place of residence is indicated.

Telephone numbers (home and work) are recorded from the patient’s words.

In lines 13 “Document certifying the right to preferential security (name, number, series, date, by whom issued)” and 14 “Disability”, an entry is made regarding the submitted document.

Line 14 includes the patient’s disability group.

In line 15, a note is made about the place of work, position. If you change your address or place of work, fill out paragraph 16.

The table in paragraph 17 “Diseases subject to dispensary observation” indicates diseases that are subject to dispensary observation in a given medical institution, indicating the date of registration and deregistration, position and signature of the doctor performing dispensary observation of the patient.

Entries in this table are made on the basis of the “Dispensary Observation Control Card” (registration form N 030/u-04).

Line 18 is completed in accordance with the results of laboratory tests.

Line 19 is filled in according to medical documentation about identified drug intolerance or according to the patient.

If a patient is hospitalized in a hospital combined with a clinic, the card is transferred to the hospital and stored in the medical record of the inpatient. After the patient is discharged from the hospital or his death, the medical record of the outpatient with the epicrisis of the attending physician of the hospital is returned to the clinic.

In the event of the death of a patient, simultaneously with the issuance of a medical death certificate, a record of the date and cause of death is made in the card.

Medical records of the deceased are removed from the existing file cabinet and transferred to the archives of the medical institution, where they are stored for 25 years.

A patient may be under observation for the same disease by several specialists (for example, for peptic ulcer disease, chronic cholecystitis - by a therapist and a surgeon); in the table of paragraph 17, such a disease is recorded once by the specialist who first took him under dispensary observation. If a patient is observed for several etiologically unrelated diseases by one or more specialists, then each of them is listed on the title page.

If the nature of the patient’s disease changes (for example, coronary heart disease is added to hypertension), then a new diagnosis is entered into the table on the title page without the date of registration, and the old entry is crossed out.

Particular attention should be paid to the entries on the sheet of final (updated) diagnoses, where doctors of all specialties enter the diagnoses established during the first visit to the clinic and for home care in a given calendar year, regardless of when the diagnosis was made: at the first or subsequent visits or in previous years.

In cases where the doctor cannot make an accurate diagnosis at the first visit to the patient, the presumed diagnosis is recorded on the current observations page; only the date of the first visit is entered on the sheet for recording updated diagnoses. The diagnosis is entered after it is clarified.

In the event that a diagnosis made and recorded on the “sheet” is replaced by another, the “wrong” diagnosis is crossed out and a new diagnosis is entered without changing the date of the first visit.

If a patient is simultaneously or sequentially diagnosed with several diseases that are not etiologically related to each other, then they are all listed on the “sheet”. In the event of a transition of the disease from one stage to another (with hypertension, etc.), the recorded diagnosis is repeated again indicating the new stage.

If, when a patient applies, a disease is discovered for which the patient has not previously applied to any medical institution, then such a disease is considered to be newly identified and is marked on the “sheet” with a “+” (plus) sign.

Diseases that can reoccur in one person several times (sore throat, acute inflammation of the upper respiratory tract, abscesses, injuries, etc.), each time they occur again, are considered newly identified and are marked on the “sheet” with a “+” sign (plus ).

All other entries in the medical record are made by the attending physicians in the prescribed manner, in accordance with current observations.

Consultations with specialists, medical commissions, etc. are also recorded here.

Outpatient medical records and child development histories are stored in the registry: in clinics - by area and within areas by street, house, apartment; in central district hospitals and rural outpatient clinics - by locality and alphabet.

Fact 1. A paper duplicate is still needed

The standard for maintaining an electronic card is enshrined in GOST R 52 636–2006, and records that comply with this GOST have the status of an outpatient card. But, since the order to maintain a paper outpatient card is still in force, it is not yet possible to limit ourselves to only the electronic version. Most often, information is duplicated in ordinary paper cards, which makes it possible to transfer data to other health care facilities that are still not equipped with a computer system or maintain electronic cards using a different program. The simplest option is to periodically print out data from the information system and enter it into a paper map.

Fact 2. Multi-accessibility

The clinic’s database is structured like this: a local network with centralized management, similar to the Internet, is created in the health care facility, protected in accordance with the requirements of the law on maintaining medical confidentiality. There is a central server where all patient information is stored, divided into individual folders. From computers at workstations, you can view or change the contents of any folder at any time, depending on the access level. Thus, the patient’s “page” can be simultaneously filled out by different departments and specialists, for example, an ophthalmologist, a radiologist and a laboratory doctor who enters test results into the card. There is no need to move the card from place to place, there is no need to hand it out to the patient each time and track its return.

Fact 3. EHR simplifies many processes

With an electronic card, your life history is always at hand; it is available in a special tab or via a quick link. This will definitely simplify and speed up working with elderly patients with mnestic disorders. Also on the patient’s page you can see a list of updated diagnoses, a list of appointments and consultations, an allergy history, and data on the carriage of infections. Without digging through a paper map, without deciphering your colleagues’ handwriting, without searching through pieces of paper folded in half, you can quickly get acquainted with the results of examinations. You can book your appointment by filling out a special form, which can be customized individually. You can attach a drawing or photo to the inspection, the results of the manipulations performed. It simplifies the computer and the issuance of appointments and directions (the part of the appointment containing recommendations is automatically printed), as well as filling out coupons and encrypting the diagnosis according to the ICD.

Hippocrates never dreamed of medical cards, medical and childbirth histories, much less electronic versions of these documents! Read on to learn how the electronic future is invading hospitals and clinics.

An electronic medical record, or electronic medical record (EMR), is an electronic document intended for maintaining medical records, searching and issuing information upon requests (including through electronic communication channels).

The task of the Uniform State Health Information System is to quickly obtain information about the volume of medical care provided to the population, so that it is easier for the state to plan medical costs and optimize the expenditure of budget funds. In the future, the Uniform State Health Information System will become very convenient for practicing doctors. If we can get it to work, consultations, hospitalizations, and transfers will be easier to process

Fact 4. EHR strengthens control

The use of electronic records makes the work of a medical organization more transparent in every sense. At any time, each record can be checked by management, insurance company, and supervisory authorities. Competent and timely internal control allows you to get closer to impeccable documentation, which will help you avoid penalties during external audits.

Fact 5. Patient access will be denied

With a complete transition to electronic documentation, patients will not have direct access to their outpatient records. The patient will not be able to take the card home for his own personal reasons or remove the results of studies or tests from it, which is convenient for the clinic, which in this case will not face fines if this card is requested for verification. The information system, if necessary, allows you to quite simply and quickly print out a statement for the patient. There are projects for more technological solutions, for example, a special memory card in the hands of the patient, duplicating the outpatient card.

Fact 6. EHR will be implemented everywhere

The creation of a unified medical information system is a state initiative, which is recorded in order No. 364 dated April 28, 2011 “On approval of the concept of creating a Unified State Information System in the field of healthcare” (Uniform State Health Information System). So sooner or later computerization will be introduced everywhere.

Fact 7. Grandiose plans

Federal-level services planned in a unified information system, for example, an integrated medical information record, imply a much higher level of storage and transmission of medical information than is currently the case. For example, if emergency or emergency hospital doctors have the opportunity to review a patient's outpatient record, this could save many lives.

What do you think?

I really like the electronic card, even though the transition to it was difficult. It is not possible to implement all functions at once, but we are getting there. Now we use it not only to keep track of cards, but also to track doctors’ working hours, payroll calculations, and a warehouse. There are many problems with training experienced specialists who come from regular clinics and have not worked on a computer. They are afraid. And young people get right up and work, they, of course, also have shortcomings, but we work, we check, it’s still easier than with paper.
Deputy chief physician for clinical expert work, polyclinic in the Moscow region

In general, in institutions that maintain an electronic medical history or outpatient card, the level of documentation is much higher. Apparently, this is due to the fact that the primary documentation is seriously checked by someone from the clinic administration.
Tatyana, medical expert at an insurance company

Still, there is no feeling of reliability from the electronic card. We’ve gotten used to cards over many years; I picked up the card and started accepting it. But on the computer you click on something wrong, and it just goes away and gets deleted, or someone else edits the map — then look for the loose ends. And it turns out to be awkward with patients. You can write a card almost without looking, but asking a patient and looking at a computer is somehow impolite. Again, if the patient has already left, the next one will immediately come in; you can put the paper card aside and return to it later, but with an electronic card it is more difficult. By the end of the day everything will be mixed up and you won’t be able to put it back together. Life doesn’t stand still, maybe we won’t be able to do without a computer later. It’s already convenient with analyses—everything is with numbers, printed, directions are drawn up by themselves.
Olga, therapist of the highest category, 16 years of work experience

The electronic map is not perfect, but it is better than scribbling. Checking boxes, instead of writing the same thing a hundred times, still saves a lot of time. But for now you have to print out the appointment, sign it and stick it on the card — this doesn’t make much sense. Moreover, if the patient came, for example, only for a rinse, he still has to register it as an appointment so that the insurance company will pay for it, and this is not very convenient. But in principle, filling out a card is no more difficult than filling out a page on a social network, so there are no problems with the database.
Larisa, ENT doctor of the first category, 11 years of work experience

Electronic medical records, as planned by experts, should replace paper ones, which from time immemorial doctors and nurses filled out and now fill out on their own. Information systems have now been implemented that allow you to see the electronic medical record of any patient in any city that is already covered by this system. But this is available only to those specialists who have access to this unified information system according to their position. Still, no one has canceled medical confidentiality; it remains.

If a person has the password, he can view the cards entered into this system.

And if he doesn’t have it, then only through his attending physician can he try to look at it.

I think that the electronic medical record can be shown by the attending physician or by order of the chief physician of the hospital upon presentation of a passport. But while people still know little about such subtleties in medicine, they use handwritten medical records when necessary.

Medical electronic records have been introduced in Russia since 2013. Several software products have already been developed - information systems, such as Samson or Medialog. They are now being tested in different regions to select the best one and make it uniform throughout Russia.

Electronic medical records are one of the modules of these information systems. They are analogues of medical histories, which in most cases are now still written by doctors by hand. Here you can read what an electronic medical record is. I’m somehow not sure that such documentation can be available to patients. Still, patients are not allowed to hand over a handwritten medical history; they are carried from office to office by a nurse or nurse, but not by the patient himself. There is the concept of medical confidentiality, which the doctor is obliged to keep. So I don’t think patients will be allowed access to the electronic medical record.

The page for this map looks like this:

Even from this picture it is clear that there may be little interest for a simple patient here. Everything is presented in professional language with special terms.

Although on another site, here, there is an indication of Patient's personal account, as a separate online service:

Perhaps, after registering through your Personal Account, you will be able to receive some information about test results, diagnosis, procedures, etc. But for this to happen, the service needs to be made available to the public.

Electronic medical records are designed to allow a doctor in any hospital or clinic to have access to a patient's medical history. They started implementing them back in 2013 and promised to completely switch to them in 2014.

But, unfortunately, even today, in 2016, not all regions work with EHRs.

To ensure the privacy of the data stored on the card, it is password protected. Doctors have access to the password. It should also be possible to access the card through the Patient’s personal account. But, unfortunately, today it is practically not implemented. Therefore, the most acceptable option now is to ask the doctor to transfer the card information to an electronic medium (flash drive).

If there is a need to view your electronic medical record (EMR), you can contact your local or attending physician and he will dump its contents onto your flash drive, and perhaps show the pages you are interested in on the monitor of your work computer. For example this:

In order to view your electronic medical record, you need to contact your local doctor at your place of residence, since the information is only on his computer and is not posted on the social network.

Electronic medical records were introduced in Russia not just yesterday. However, this system does not yet cover all settlements, of course. I am almost sure that a resident of a small remote village will not be able to view his electronic card even if he wants to. Technical capabilities are not enough.

As for larger places, you need to know:

Our electronic card, if it has already been created, is not open to the entire curious public. Medical confidentiality will remain so and will remain so. There is no need to type your name on the Internet; fortunately, this will not give you anything.
But if you want to see all the correspondence between your condition, the services received and what is written on the card, you need to go to the clinic to which we are attached. And there you can talk with your local and attending physician. He will tell you at what stage the map development is. And it will probably show the pages on the monitor screen.

If there is such a need, then you need to take a coupon for an appointment with a local therapist and already at the appointment voice your desire to see it, you can approach the head nurse (you will get to her faster than a doctor) with such a request - they will not refuse. But the electronic card will have the same thing, the same data as the paper card.
An electronic card is not a document that a patient can see in the public domain until the electronic system is adjusted. Not all doctors yet have computers in their offices, there are no terminals for electronic insurance policies, and doctors protect diseases from the patient himself. They don’t give you a regular card, and even less so now they won’t give you an electronic card. Until they decide how to encrypt data that the patient does not need to see.
And the most interesting thing is that the patient must collect the data for the electronic card himself. That is, it will no longer be the same card that is kept in the clinic.
That is, doctors see on their computers all the patient’s illnesses, how sick they were, where they were treated. But the patient can only see the names of the diseases.
Doctors are against patients seeing the drab work of doctors, and doctors are against frightening patients with scary names of diseases.
But you can try to see it in the therapist’s office if he agrees to print out your medical history for you.
To be honest, I didn’t even know that there was such a new opportunity to view your electronic medical record. It turns out that the attending physician does not have the right to refuse you, and at your first request he should, without any questions, transfer the information available about you about your state of health to your flash drive or portable hard drive.
My relative works in one of the hospitals as a programmer. It was he who began to implement, as Tew correctly writes, this Samson information program. I asked him everything). This is such a special program throughout Russia. Doctors enter all the information about patients into the computer into this program. And in Moscow, for example, they can come in and immediately read everything and give advice or comments. He also says that doctors still keep medical records by hand, because this way there is more trust. Electronic medical records are not shown to any of the patients, and patients do not ask about these records because they do not know about them).

Form 025/у 04 was put into circulation in 2004. The form was developed by the Ministry of Health. Approving document - Order number 255. An outpatient medical record, form 025/u 04, is used by institutions providing outpatient care (without providing a bed).

Form 025/у 04 is filled out during the patient’s initial visit to an institution or when visiting a 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 a 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 patient’s main diagnosed diseases. 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. These data play a major role in the provision of certain types of emergency care and 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 the largest shipping companies, and can send purchases to any region of Russia. Postal delivery to the desired location is possible.

What is an outpatient card? You will learn the answer to this question from this article. In addition, your attention will be presented with information about why such a document is being created, what items it includes, etc.

General information

An outpatient card is a medical document. In it, attending physicians keep records of the prescribed therapy and medical history of their patient. It should be noted that such a card is one of the main documents of a patient who is undergoing treatment and examination in an outpatient and outpatient setting. The form of the medical record is the same for everyone. This document is created for each patient upon his first visit to the hospital.

Medical record and its role in practice

An outpatient card, first of all, serves as the basis for any legal actions (if any). Moreover, correctly filling out a patient’s medical history has great educational significance for the doctor, as it strengthens his sense of responsibility. It should also be noted that this document is very often used in insurance cases (in case of loss of health of the insured person).

Incorrectly completed cards

If an outpatient’s medical record was filled out inaccurately or was lost by the registry, then patients can make justified claims against the institution. By the way, in some clinics there is such a practice as intentional loss. Typically, this happens with poor clinical outcomes, errors in the prescription of medications and procedures, etc.

One of the means of improving the safety of outpatient records is the introduction of their electronic versions. But this method has two sides: thanks to such documents, you can quite easily track the sequence of their changes, however, the issued electronic card does not have any legal force.

The outpatient medical record includes forms for immediate and long-term information. Let's consider their content in more detail.

Operational information forms consist of formalized inserts for recording the patient’s first visit to the doctor, as well as for patients with influenza, sore throat and acute respiratory disease. In addition, they contain inserts for return visits for the consulting committee. Such forms are filled out as the patient visits the doctor at home or during an outpatient appointment, and are glued to the spine of the card.
Long-term information forms contain warning marks, information about preventive examinations, sheets for recording already specified diagnoses and sheets for prescribing any narcotic drugs. These inserts are usually attached to the card cover.

Basic principles of charting

An outpatient card is required for:

descriptions of the patient’s condition, treatment outcomes, therapeutic and diagnostic measures and other information;
maintaining the chronology of events that influence organizational and clinical decision-making;
reflections of physical, social, physiological and other factors that influence the patient throughout the pathological process;
understanding and compliance by the attending doctor with all legal nuances of his activities, as well as the significance of medical documentation;
recommendations to the patient after completion of the examination and completion of treatment.

Requirements for card registration

The outpatient card must be filled out by a doctor strictly according to the rules. He must:

Each entry is signed only by the attending doctor with a transcript of his full name. Entries that have nothing to do with the care provided to the patient are not permitted. All notes in the medical record must be thoughtful, logical and consistent. Particular attention is paid to those records that were kept in complex diagnostic cases, as well as in the provision of emergency care.