Electronic map: facts and opinions. Patient electronic medical record

Online services allow you to independently maintain medical records, accessible through mobile applications on your smartphone or through websites.

Services for maintaining medical records:

• monitor well-being;
• monitor medication intake;
• allow ;
• inducted into the course latest news in the world of medicine;
• calculate vital medical indicators;
• transmit health data to doctors via email;
• stored in the phone medical documentation: certificates, test results, sick leave certificates, x-rays.

Services for maintaining medical records are designed to make life easier and health stronger. We offer 6 services for maintaining medical records and other features that may be useful to you.

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Mobile application Medical Note

Medical Note - medical assistant for the whole family. This medical application combines the functionality of the most popular mobile applications in the “Medicine” and “Health” categories.

With Medical Note you can:

• create a medication schedule;
• mark the dates of onset of illness and recovery;
• find a hospital or clinic near your home;
• mark health-related events on the calendar;
• save information about procedures, test results, gadget readings and the history of visits to the doctor.

The Medical Note program is also convenient because you can connect the accounts of your loved ones to your profile and enter data into the calendar. The application is available on iOS platforms and Android.

Installs for free.

Medical card from AvvaStyle

AvvaStyle is a mobile application that can save information about your health status (pulse, temperature, blood pressure), and allows you to always have various documents with you (all kinds of certificates, results, vaccinations, sick leave).

The program allows you to create medical events (for example, schedule a trip to the doctor), remind you in time to take medications or get an injection. There is also a medical calendar and a calculator that allows you to monitor your vital signs.

The application is free and suitable for the whole family.

Online service and mobile application ONDOC

ONDOC is a health monitoring service integrated with medical institutions. The service analyzes information from Apple Health, saves the history of visits and doctor’s appointments, and makes an appointment with the right specialist.

The program is also convenient because data about your health, for example, test results provided by any clinic of this service, goes directly to the program’s medical record.

The application unites 490 medical institutions throughout Russia.
All ONDOC functions are available both in mobile application, and on the website ondoc.me.

The program is free.

Medical card - healthy patient

Medical card - a healthy patient - an analogue of a paper medical card in a clinic. Only the data is not saved in paper form, but in electronic form on a smartphone or tablet.

You can take photographs of documents in a medical facility, add and store them in the application. It is possible to download files from mail, gallery, Google.Disk, Yandex.Disk and any other sources. Documents can be searched by date, name of the sick person, name of the test and clinic. It is possible to send files by email, Facebook or messenger.

The developers declare complete confidentiality, since the program does not support the “cloud” and does not transfer data anywhere. It is possible to store documents of all family members.

The application is free.

Medical card MEDDATA

MEDDATA - the first electronic medical card in Russia, which provides access to personal medical data from any country in the world. If suddenly you need urgent Care, medical staff will be able to quickly open access to data, and in any country.

With this application you can store information about your health in one place, track important indicators, always keep abreast of news in the healthcare field and consult with doctors, including using telemedicine technologies.

MEDDATA is available as a free mobile app and as a web version.

Doxter medical card

Doxter, a service for maintaining medical records, is a personal medical record in a smartphone. This mobile application has four sections.

The “Indicators” tab displays information about temperature, blood pressure, pulse rate, weight, cholesterol, hemoglobin and sugar levels. If necessary, you can add personal sections.

The “Diseases” tab contains the medical history. Symptoms, prescribed therapy, names of doctors are entered here, and photos of prescriptions for medications prescribed by the doctor are attached.

The “Reminders” tab is an alarm clock that reminds you to visit a doctor or take medicine. You can add comments to the alarm clock and customize it to the tasks set by the patient. The app has a calendar where you can mark upcoming medical events.

The “Profile” tab contains your personal information: information about blood type, weight, height, vaccination, allergic reactions. Free version The application allows you to add up to 10 entries to each section. There is a function for copying information to the cloud.

The program allows you to send all information by email.

Programs for clinics and medical centers

Cloud medical information system. The functionality includes online registration, reception and registration of patients, services, electronic medical records, staffing table doctors, analytics and reporting.

Platform for organizing the work of private medical and dental clinic. Allows you to effectively organize the work of the clinic: make appointments for patients, maintain electronic medical records, issue invoices, automatically generate contracts, receive summary statistics of work and much more.

Full-featured medical information system: management of a clinic, hospital, medical center and network of medical institutions + SaaS solution for website organization electronic registry and the clinic patient’s personal account.

Online system for automating administrative, economic, treatment and diagnostic processes in medical institutions. There are versions for medical centers, dentists, veterinary clinics. There is a stationary version

Simply a convenient medical information system that allows you to maintain a patient database (medical cards - examinations, tests, diagnoses...), create a schedule of appointments with doctors, send SMS/Email reminders to clients, keep records of income and expenses, materials in stock, employee records and salaries, organize marketing campaigns, study analytics.

Cloud medical system management private clinic. Easy interface, flexible settings, convenient scheduling of doctors, mobile version, integration with the site.

Medical information system. Suitable for both small private clinics with 2-3 workstations, and for large medical diagnostic centers from hundreds of jobs. There is a cloud version of MedWork Cloud

System to support work medical institution. Automates the full cycle of interaction with the patient when providing medical care in an outpatient clinic, hospital, or sanatorium. Maintaining an electronic medical history: doctor's appointments, laboratory diagnostics, research. Accounting for consumables and personalized accounting of medications

Cloud medical information system. Ensures the work of all doctors. Online access for patients to doctors’ schedules, records and medical history. Storage of archival documentation. Billing.

Convenient program for managing a clinic. Online scheduling, salary calculation, revenue monitoring, client base

Cloud automation system for a medical facility. Maintaining an electronic patient record. Control of doctors and patients. Patient's personal account on the website. Online appointment booking.

Powerful professional MIS at the price of systems entry level. WEB technologies combined with reliable means of protecting personal data make MGERM indispensable for automating network clinics.

The solution “1C-Rarus: Medical Organization Management” was developed with the methodological support of MIACRAMS and is intended for complex automation of large medical organizations any form of ownership, with outpatient and inpatient units.

A software product for medical organizations that provides effective automation of business processes when providing services in outpatient settings: consultation with specialists, diagnostic services, medical examinations, medical commissions.

A program for automating and simplifying the work of multidisciplinary clinics, medical centers, beauty salons, veterinary clinics, etc. Created on the basis of the widely proven dental program Dental4Windows, with which it is fully compatible. Qualified technical support service, assistance in installing and configuring program functions.

Information system for clinics and diagnostic centers. Standardizes work with documents and integrates clients, personnel and equipment into one information system so that everything is transparent. Functionality includes online recording, Personal Area on the clinic website, maintaining an EHR, CRM, calculating employee motivation, analytics, telephony, warehouse, chat.

Program for private clinics. Allows you to control the workload and work schedule of doctors and offices, the consumption of medicines and materials, and automate fiscal, management, financial and accounting. Supported international protocols transfer of information when integrated with medical and laboratory equipment, devices and external information systems, television panels, information kiosks and electronic queuing systems.

Clinic "Center of Israeli Medicine"

After carefully studying the business management programs available on the market, the management of the Alternative Center for the Development of Children and Adults purchased a licensed copy of the USU program.

This was due to the fact that the program has great capabilities, from registering a client for consultations to tracking current income and expenses.

What we first paid attention to when choosing: there were many solutions on the market, but they were somehow incomplete, that is, in order to fully satisfy the needs for organizing work, it was necessary to purchase several services and programs. Options were selected, but none of them suited us at least 80%. The monstrous clutter of the interface, the intricate control logic, and the overabundance of unnecessary functions scared us away. In the end, the choice fell on USU. The program contains everything you need to work in managing a small medical center.

You can customize the program to suit your needs, your business processes, which is what we did. We completely abandoned keeping paper schedules and records, that is, we switched to an almost paperless organization of administrative work.

Helpdesk if needed short time provides assistance in operating the program.

No subscription fee, possibility of purchasing required quantity copies of the program are a viable solution.

Our leadership considers the USU program best offer on the market specifically for use in small organizations.

Director of the Center for the Development of Children and Adults “Alternative” Reshetnikov V.V.

"USU"- a wonderful program with a very convenient and accessible interface. Its capabilities made it possible to solve many of the clinic’s problems in automating the process of creating patient databases, recording visits, and admissions Money, issuance of gift and bonus cards and consumption of medications.

The program's potential makes it easy to expand its functionality to suit individual needs. Many built-in options will allow you to improve process automation without significant investments on an existing basis.

Technical support deserves special attention. Help is always prompt and very qualified.

Our clinic uses the “Beauty Salon 3.0” system.

Very convenient interface: Directories are filled out logically and clearly.

It is possible to correct data at any time simply by clicking in the right place. It is very easy to interact online when booking clients for various procedures.

What is especially attractive is the good setting of prices for services and the ability to manage data for both services and goods: how to take into account Consumables for procedures and implementation accounting additional products for clients. Good reporting system for all clinic activities.

Head Kan Z.A.

LLC "Light"

We purchased the program from you in the summer of 2013 and have been actively using it ever since. The program interface is simple, all employees quickly mastered it. If we have any questions, we contact the developers and receive technical support every time. We are planning to order modifications.

Every person has probably been to a medical institution, where one of the most important documents is the medical record of an outpatient. Neither the doctor nor the patient can do without it.

Why is an outpatient card necessary?

How correctly this document is filled out may determine the fate of the patient in the framework of a possible criminal or civil case being investigated in relation to him.

An extract from the outpatient card is required:
⦁ when carrying out forensic medical examinations;
⦁ to make payments for the provision of medical care under compulsory medical insurance contracts;
⦁ to conduct medical and economic examinations to monitor the quality of medical services provided.

What is a patient's outpatient card?

In approved in November 2011 Federal Law No. 323, which regulates the health of our compatriots, there is no such thing as medical documentation.

The medical encyclopedia includes a system of documents that have a prescribed form, the purpose of which is to register information about measures for prevention, treatment, diagnosis and sanitary hygiene.

Medical documentation can be accounting, reporting and accounting. Medical card outpatient belongs to the first category. It describes the diagnoses, the current condition of the patient, and recommendations for treatment.

Introduction of the updated form

Order of the Russian Ministry of Health No. 834 of December 2014 approved updated unified forms of documentation used by outpatient medical institutions. It also states how they are filled out.

This is a significant step towards the creation of an electronic medical record, since the introduction of uniform standards in the execution of records ensures mutual continuity among medical institutions.

In particular, form No. 025/u - “Medical record of an outpatient patient” has been developed, and it is described in detail how it should be filled out. In addition, a sample patient coupon with the appropriate filling procedure has been approved.

The above-mentioned order gave this card the status of the main account medical document an institution providing medical care for the adult population using outpatient conditions.

How is it different from the old form?

In the new accounting form, the information content has been significantly increased, and the positions to be filled out have been specified in more detail. In the previous version, the doctor could make notes at his own discretion; now they are unified.

The following information was required to be entered:
⦁ about consultations with narrow medical specialists and the head of the department;
⦁ about the result of the meeting of the All-Conference Committee;
⦁ about carrying out x-rays;
⦁ on making a diagnosis according to the 10th International Qualification of Diseases.

For each specialized medical institution or their specialized structural area in dentistry, oncology, dermatology, psychology, orthodontics, psychiatry and narcology, its own outpatient card. Form No. 043-1/u, for example, is filled out for orthodontic patients, No. 030/u is intended for a control card for dispensary observation.

Form No. 030-1/u-02 is issued for persons suffering psychiatric diseases and drug addiction. It was approved in Order of the Ministry of Health of the Russian Federation of 2002 No. 420.

How is it filled out?

During a person’s very first visit to the clinic, the receptionist fills out the data on the title page. But a patient’s outpatient card can only be filled out by doctors.

If the patient falls into the category federal beneficiaries, “L” is placed next to the card number. The doctor must make an appropriate record of each patient’s visit to the clinic.

The outpatient card reflects:
⦁ how the disease progresses;
⦁ what diagnostic and therapeutic measures consistently carried out by the attending physician.

The entry is made carefully, in Russian, in the appropriate section without any abbreviations. If it is necessary to correct something, this is done immediately after the mistake is made and must be certified by a doctor’s signature.
It is acceptable to use Latin to write the names of medications.

The health worker fills out the first sheet in the registry according to the data from the patient’s identification documents. Workplace and position graphs are recorded according to the patient’s words. The form contains recommendations for completing each section.

Filling principles

When filling out an outpatient card, you should remember some basic principles.

It should chronological order be described:
⦁ in what condition the patient came to see the doctor;
⦁ what diagnostic and healing procedures carried out;
⦁ treatment results;
⦁ circumstances of a physical, social and other nature that influence the patient during pathological changes his well-being;
⦁ the nature of the recommendations given to the patient at the end of the examination and treatment process.

The doctor must comply with all legal aspects when filling out the form.

The outpatient card consists of forms on which long-term and operational information is recorded.

Long-term information contained on front-adhesive sheets includes:
⦁ information copied from an identity document;
⦁ blood group with Rh factor;
⦁ information about transferred infectious diseases and allergic reactions;
⦁ final diagnoses;
⦁ results preventive examinations;
⦁ list of prescribed narcotic drugs.

Operational information is recorded on inserts where the results of the initial visit and secondary visits to the local therapist, specialized doctors, and consultations with the head of the department are recorded.

Extract from outpatient card

An extract is a medical certificate of health in form 027/y, which belongs to the second group of medical records documentation. It contains information about previous diseases during outpatient treatment.

Its purpose, like all the documentation of this group, is to quickly exchange data on the health of patients, which helps to connect the individual stages of sanitary-preventive and therapeutic measures.

The extract can be provided by the patient to the employer to inform about the completion of outpatient treatment. It is not subject to payment, but is rented together with sick leave, if the latter is issued for more than a month.

This document allows you to be exempt from classes in educational institutions.

The extract contains information about the patient, indicating the medical policy number, listing his complaints, symptoms of the disease, the results of medical examinations and examinations, as well as the primary diagnosis.

All information must fully correspond to that contained in the outpatient card.

The extract can be used to prescribe further medical procedures.