Medical certificate 025. Outpatient card of the patient: description, form, sample and extract. What is the difference from the old form

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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 registration medical document of 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 divisions in the fields 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 secondary vocational education conducting 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 citizens entitled to receive a set of 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 the 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 (injury, 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 the names of medicinal products 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 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. 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 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. 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, for peptic ulcer disease by a general practitioner and a surgeon), each such disease is indicated once by a medical specialist , the first to establish dispensary observation. If the patient is being 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 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 contains information about hospitalizations performed, paragraph 31 - information about surgical interventions performed, and 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. 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 departure, the epicrisis is sent to the medical organization at the place of medical observation of the patient or given to the patient.
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.

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 dispensary observation is carried out:

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.

Such a card is filled out by the registrar of any medical institution providing treatment to patients. When a person goes to the clinic for the first time, he needs to present his passport, and a medical card is issued for him. It is then stored in the registry of the medical institution.

Extract from the medical record of an outpatient

If a person is scheduled to have a consultation with a specialist who is seeing him in another medical institution, he will need to provide an extract from his permanent card. To do this, you need to visit a doctor and order such a document. This procedure requires additional time.

Buy an outpatient medical card

Often, the patient’s life and health depend on how quickly assistance is provided or surgery is performed. To receive an extract from your card, you need to waste a lot of time. We offer the opportunity to buy an outpatient medical card, an inpatient medical card.

Filling out an outpatient medical record

Our specialists are very careful when preparing medical books, certificates, and documentation, so an outpatient medical card purchased from us in Moscow will contain all the necessary information about the patient and clearly indicated diagnoses. Such a document will contain all degrees of protection, seals and signatures of the attending physicians.

Insert sheet for an outpatient medical record

The card itself contains a small number of sheets, so if there is not enough space, loose sheets are used. They must be securely attached.

New outpatient medical record

We offer the service of issuing such a medical card. You need to call and place an order. Our specialists will immediately begin work. On the same day, the completed new outpatient medical record will be in your hands.

With such a document, you will be able to apply to any medical institution and continue treatment with the selected specialist. Delivery is carried out using a courier service.

Medical record of an outpatient in cosmetology

Often, many patients have allergic reactions to certain groups of medications, so some cosmetics are contraindicated for such a client. An experienced cosmetologist always keeps a special card so that he knows about his patient’s medical contraindications.

Outpatient medical record 2015

This year, a new type of card has been introduced that is mandatory for use in medical institutions. They also reflect the necessary information about the patient, previous diseases, test results, and vaccinations performed. They also contain records of doctors examining the patient.

Outpatient medical record 025 u

We will be able to produce such a card on the day of your request, it will be filled out in accordance with the current legislation of Russia.

The patient's medical record, form 025, is the source material for issuing various types of certificates necessary for entering work, studying or leaving the country.

Medical card 025 y 04

It is issued at a medical institution and is provided for each patient. We offer to buy such a card inexpensively and arrange delivery to any district of Moscow.

Medical card 025 u in Moscow

Moscow is a big city, so there are many different medical institutions open, and it will take a very long time to obtain any document. We offer medical record production services. Such a document is prepared quickly, is legal and can be presented to any doctor.

Medical card 025 from doctors

Medical record 025 contains all information about the patient. A person undergoes medical examinations, visits specialists, ophthalmologists, endocrinologists. Each doctor makes his own notes on the document, stamps and signs. When accessing again, new records appear. Such a map is the history of each person’s treatment.

Medical card 025 buy

If the card is urgently needed, for example, you moved to Moscow from another city. You can buy this form from us. The order is placed over the phone, then we independently process all medical records.

We offer an affordable price because all doctors are local. These are real doctors, we guarantee the authenticity of the issued document.

Outpatient medical record form 025

Such a card will allow you to complete the required legal formalities and continue treatment in any medical institution.

Our medical card form 025 has a low cost, so it is available to anyone. We produce the document on the day the order is placed. You don't even have to come. You need to provide us with your information, and we will draw up the document without your participation.

When such a card is ready, our administrator will call you back. Next, the courier will deliver the already completed card to any location you choose.
Here you will find:

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 needed?

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 Federal Law No. 323, approved in November 2011, regulating the health protection 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. The outpatient medical record falls into 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 registration medical document of 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 taking 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 has been developed. 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 from 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 belongs to the category of federal beneficiaries, an “L” is indicated 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 are 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 describe in chronological order:
⦁ in what condition the patient came to see the doctor;
⦁ what diagnostic and therapeutic procedures were performed;
⦁ treatment results;
⦁ circumstances of a physical, social and other nature that influence the patient during pathological changes in 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 previous infectious diseases and allergic reactions;
⦁ final diagnoses;
⦁ results of 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 illnesses suffered 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 submitted together with the sick leave certificate, 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.

Outpatient patient card form 025 y 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 to carry out the treatment process 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 the patient’s existing chronic diseases, allergic reactions, and disability.

Completeness and accuracy of data entry plays an important role in making diagnoses and prescribing treatment. The lack of important information, for example, about the presence of allergic reactions, can lead to serious negative consequences and harm 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 card reflects the results of examinations, 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. The results of laboratory and functional research methods are attached.

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.