Record in the case history 7 letters crossword puzzle. By keeping records in the medical history. In military medical institutions

General provisions. The most important aspect of the work of a doctor in a hospital is to keep a patient's medical history. This is a document that contains all the necessary information about the patient, the development of his disease, the results of clinical, laboratory and instrumental examinations, the validity and effectiveness of the surgical and conservative treatment. The medical history is of great practical, scientific and legal importance. It contains all the data obtained during the examination and treatment of the patient. It should be conducted consistently and clearly, concisely and to the point, observing the principle of "minimum sufficiency", i.e. reflecting in the text no more, but no less than what is necessary for a sufficient understanding of the patient and his treatment. In the case history, the time (day, month, year, hour) of any entry is noted. Abbreviations of words in the text of the case history, except for the generally accepted ones (i.e., because), are unacceptable. All entries in the medical history, as well as the signatures of doctors and nurses, must be clear and legible.

The title page is filled out upon admission of the patient to the emergency department. Although this section of the medical record is completed by the Registrar Nurse, the physician checks this information and makes necessary adjustments if necessary. In the "Drug intolerance (allergy)" section, not only should the intolerance of individual drugs, foods, etc. be indicated, but also the nature of the observed adverse reactions should be noted. An entry in this column (as well as a note on the title page about the patient's blood type and Rh affiliation) must be accompanied by a legible signature of the attending physician. At for the first acquaintance with the patient, it is also necessary to make a note in paragraph 15 on the 2nd page of the title page about the patient's incapacity for work in the period preceding hospitalization (for example, a certificate of incapacity for work from ... to ..., or there is no certificate of incapacity for work; disability group).

For a patient hospitalized by emergency showingniyam, a record of the doctor of the admission department with a justification for the need for emergency hospitalization and treatment in a hospital is obligatory. This record should contain the patient's complaints, the history of the present illness, a summary of the life history, objective examination data, diagnosis, list and justification of the necessary studies and medical manipulations or surgical interventions performed urgently in the emergency department (in accordance with the instructions of the Ministry of Health of the Russian Federation on mandatory studies at LOR-diseases).

A necessary prerequisite for any medical

intervention at all stages of the patient's stay in the hospital is informed voluntary consent(Article 31 "Fundamentals of the legislation of the Russian Federation on the protection of the health of citizens"). This consent must be based on sufficient information obtained from the healthcare professional in an understandable form about the possible options for medical intervention, the proposed methods of diagnosis and treatment, and the consequences of their use for health. In the medical departments of the I City Clinical Hospital of Moscow, it is customary to document this consent with the signature of the patient in the medical history.

A specific age is legally established - 15 years, after which the patient has the right to independently make a decision without notifying the parents, i.e. he himself can exercise his right to give such consent (Article 32 of the Fundamentals of the Legislation of the Russian Federation on the Protection of the Health of Citizens). Consent to medical intervention in respect of persons under the age of 15 is given by their parents (guardians). Ignorance of this provision by doctors (especially surgical specialties) can lead to a violation of human rights (of the patient or his guardian). Consent to medical intervention for citizens recognized as legally incompetent (alcoholism, mental disorders, senile dementia, etc.) is given by their legal representatives - guardians - after providing them with information about the patient's state of health. In the absence of legal representatives, the decision on medical intervention is made by a council, if it is impossible to convene a council for urgent pathology - directly by the attending (duty) doctor, followed by notification of officials of the medical institution and the legal representatives of the patient.

It is not allowed to disclose information about the patient that constitutes a medical secret (health status, features of the operation, test results, prognosis of the disease, etc.) without the consent of the patient (Article 61 of the Fundamentals of the Legislation of the Russian Federation on the Protection of Citizens' Health).

In the department, a patient hospitalized for emergency reasons should be examined by the on-duty doctor of the hospital upon admission. In the case history, a brief entry is made outlining the main complaints, anamnesis of the disease, ENT status and the general status of the patient. The purpose of the patient's admission to the department is indicated, if indicated, an urgent general and laboratory examination is carried out in accordance with the instructions of the Ministry of Health of the Russian Federation on mandatory studies, medical prescriptions are made for the treatment of the patient, column 9 "Preliminary diagnosis (diagnosis upon admission)" is filled in the standard title page.

The attending physician in the department examines the patient per day

receipt (if it is delivered to the department before 14.00 working day) and no later than the 2nd day from the moment of receipt, corrects medical appointments. At the same time, the patient is examined by the head of the department and, if necessary, a consultant. The clinical diagnosis is put down in the appropriate column on the title page of the case history no later than 3 days from the day the patient was admitted, except for cases that are difficult to diagnose (in column 10, all LOR diagnoses are entered).

The final (final) diagnosis is made by the curator at the patient's discharge, and in column 11 they enter: a) the main diagnosis (one), for which treatment was carried out and the outcome and time of treatment were determined; b) concomitant ENT diagnoses. A concomitant general diagnosis, reflecting the pathology of other organs and systems, is entered in column 11 c. In column 116, the complications of the disease are recorded (which ones, when they arose). In column 13, information is entered on the surgical intervention (what, when), on the developed complications.

The head of the department examines patients upon admission, together with the attending physician, establishes a clinical diagnosis, determines a plan for examination and treatment. The day before the operation, the head examines the patient again and signs the preoperative epicrisis. Subsequently, by conducting weekly rounds of the patients of the department, the head makes the necessary adjustments for the management of patients, which is reflected in the case history. Finally, the head examines the patient before discharge, about which the attending physician makes an appropriate entry in the case history. In complex clinical cases, the attending physician and the head of the department take measures to call consultants (neurologist, ophthalmologist, etc.), organize a consultation together with the head of the department or his deputies (professor, associate professor) for medical work. The head of the department, as an official, bears full legal responsibility for the treatment and stay of the patient in the department.

Doctors of variable composition (training residents, interns, doctors at the workplace) conduct clinical documentation only under the guidance of the head of the department and permanent doctors (senior resident, staff doctors, teachers of the department). Examination of patients, all therapeutic measures, including surgical ones, are performed by doctors of a variable composition only under the guidance and with the participation of a doctor of a permanent composition.

The attending physicians (staff and cathedral) examine patients daily, clearly reflecting in the diary entries the dynamics of the patient's condition and medical appointments. In difficult clinical cases and in the first 3 days after surgery, more detailed records are made. If from-

due to the severity of the condition, there is a need for dynamic monitoring throughout the day, the doctor on duty makes repeated entries in the medical history, reflecting the change in the patient's condition and the nature of the ongoing therapeutic measures. Weekly rounds of patients in the clinic and clinical analysis in difficult cases are carried out by the head of the department and his deputies. Their conclusions and recommendations are recorded by the attending physician in the medical history.

Diagram of the medical history. Examination by the attending physician together with the head of the department.

Date and time of inspection. Complaints: 1) on the state of ENT organs; 2) on the state of other organs and systems.

Disease history. Anamnesis is subjective(according to the patient): the first signs and time of onset of ENT disease, the dynamics of its course, the nature of the previous treatment, its effectiveness (in detail); if surgical treatment was previously performed, if possible, indicate its volume.

Anamnesis objective: 1) data on certificates, radiographs and other documents on ENT disease; 2) the same for other diseases.

Anamnesis of life. Information about heredity, briefly - about existing diseases of other organs and systems (diabetes mellitus, mental illness, damage to the cardiovascular system, etc.), past infectious diseases (tuberculosis, sexually transmitted diseases, viral hepatitis, AIDS or HIV infection) , about working and living conditions, about bad habits (drug use, substance abuse, smoking, alcohol consumption, etc.). The presence of allergic manifestations (intolerance to drugs, certain foods, bronchial asthma, Quincke's edema, eczema, allergic rhinitis) is noted both in the patient himself and in his parents and children. Indicate whether the patient has previously received treatment with corticosteroids.

present state ( status praesens ). General condition (satisfactory, moderate, severe). Position of the patient (active, passive, forced). Physique (normosthenic, hypersthenic, asthenic). Nutrition (high, low, normal). Skin and visible mucous membranes: color (pale pink, cyanotic, icteric, pale, earthy); the presence of pigmentation, rashes, telangiectasias, scars, trophic changes. Subcutaneous adipose tissue (development, places of the greatest deposition of fat), edema (localization, prevalence, severity). Peripheral lymph nodes: localization of palpable lymph nodes, their size, texture, soreness, mobility, fusion with each other and with surrounding tissues, the condition of the skin over the nodes. Nervous system. Consciousness (clear, confused). Availability

neurological disorders. Meningeal and focal symptoms. Functions of the cranial nerves: visual acuity, diplopia, ptosis, range of motion of the eyeballs, pupillary response to light, symmetry of the nasolabial folds with teeth bared; the position of the tongue when protruding.

The state of the psyche. Orientation in place, time and situation, matching intelligence to age.

Musculoskeletal system(state of muscles, bones, joints).

The circulatory system. Auscultatory heart sounds, rhythm, arterial pressure, pulse.

Respiratory system. Respiratory frequency. In the presence of shortness of breath, indicate its nature (inspiratory, expiratory, mixed). Percussion of the lungs (clear pulmonary sound, dull, boxed, tympanic). Auscultatory: pulmonary breathing weakened, increased; vesicular, hard, bronchial.

Digestive organs. Palpation and percussion of the abdominal organs (liver, spleen). Physiological departures.

Urogenital system. Dysuric disorders, definition of Pasternatsky's symptom.

Endocrine system. Increase or decrease in body weight, thirst, feeling of hunger, sensation of heat, chills, muscle weakness, eyes shining. Palpation of the thyroid gland (size and consistency, pain).

ENT organs. During external examination, pay attention to the appearance of the ENT organs. They note changes in the shape of the external nose, the projection area on the face of the walls of the frontal and maxillary sinuses, the auricle, the neck (for example, "there is a retraction of the back of the nose in the bone section", "displacement of the nasal pyramid to the right", etc.). Before endoscopy of the corresponding ENT organ, regional lymph nodes, anterior and lower walls of the frontal sinuses, exit points of the first and second branches of the trigeminal nerve, anterior walls of the maxillary sinuses, cartilages of the larynx, etc. are palpated. All ENT organs are sequentially examined.

Nose and paranasal sinuses. Nasal breathing is examined using a cotton swab test, which allows you to evaluate it as free or difficult (difficulty inhaling or exhaling). If necessary, conduct rhinopneumometry.

If there are complaints about a disorder of smell, odorimetry is performed using a set of odorous substances: 0.5% acetic acid solution (No. 1), 70% ethyl alcohol solution (No. 2), valerian tincture (No. 3), ammonia (No. 4). For a more accurate study of the sense of smell, olfactometers are used.

Anterior rhinoscopy carried out sequentially

right, then left. Separately for both sides, the state of the vestibule of the nasal cavity is recorded, attention is paid to the type of mucous membrane (color, luster, moisture), the location of the nasal septum (in the presence of deformation, its nature, localization, severity, predominant displacement in one direction or another are indicated), the size of the turbinates, the width of the lumen of the nasal passages, for the presence of discharge in their lumen and its nature (mucous, purulent, hemorrhagic secretion, crusts). If necessary, determine the contractility of the nasal mucosa during anemia.

Nasopharynx (epipharyngoscopy). The nasopharynx is examined with posterior rhinoscopy or with an endoscope. The state of the mucous membrane, pharyngeal (adenoids I, II or III degree, signs of adenoiditis) and tubal tonsils, pharyngeal opening of the auditory tube, the view of the posterior edge of the vomer, the lumen of the choanae, the posterior ends of the turbinates, the presence and nature of discharge in the posterior parts of the nasal passages are noted. If necessary, conduct a finger examination.

At oroscopy pay attention to the condition of the oral mucosa, teeth and gums (presence and severity of dental caries, periodontal disease, periodontitis), excretory ducts of the salivary glands.

Oropharynx (mesopharyngoscopy). Mucosa (color, luster, moisture), condition of the palatine arches (hyperemic, infiltrated, edematous, soldered to the tonsils), size of the palatine tonsils (behind the arches, hypertrophy I, II, III degree), their surface (smooth or bumpy) , the condition of the lacunae (not expanded or expanded), the presence of a pathological secret in them (when pressed, caseous, purulent plugs, liquid, thick purulent discharge are released), the condition of the mucous membrane and lymphoid formations of the posterior pharyngeal wall. Swallowing function: evaluate the symmetry and mobility of the soft palate.

hypopharynx (hypopharyngoscopy). The symmetry of the walls of the pharynx (pear-shaped pockets), the presence of salivary "lakes" or foreign bodies, the size and condition of the lingual tonsil. The pits of the epiglottis are normally free.

Larynx. Normally, the larynx is of the correct form, passively mobile, the symptom of cartilage crunch is pronounced. Palpation of regional lymph nodes. With indirect laryngoscopy, the condition of the mucous membrane of the epiglottis, aryepiglottic and vestibular folds, the region of the arytenoid cartilages, and the interarytenoid space are assessed. Normally, it is pink, moist, shiny, with a smooth surface. The vocal folds are mother-of-pearl-gray, symmetrically mobile during phonation, completely close, when inhaling the glottis is wide (normally from 15 to 19-20 mm), prepared

Ears (otoscopy). During external examination, they consistently reflect the shape of the auricles, the presence of inflammatory infiltrates, wounds in the parotid region, changes in the shells and external auditory canals. Pain is assessed on palpation of the parotid region, tragus and external auditory canal.

Otoscopy is performed first on the side of the healthy, then the affected ear; if both ears bother the patient, then start with where there is no discharge. Evaluate the nature and amount of discharge in the external auditory canal (discharge mucous, purulent, hemorrhagic, in the amount of 1-2 quilted jackets or more, odorless or with an ichorous odor), the width and shape of the external auditory canal (the presence of inflammatory skin changes, sulfuric masses, exostoses , overhanging of the posterior-upper wall).

When describing eardrum(Mt) pay attention to its color (normally gray with a pearly tint) and identification points: a short (lateral) process and a handle of the malleus, a light cone, anterior and posterior malleus folds. In pathology, Ml can be hyperemic, infiltrated, retracted or bulging, thickened, the light cone is shortened or absent. In the presence of perforation, its dimensions, localization, shape, type (marginal, rim) are determined; gaping or there is a pulsating reflex. Sometimes, through a large perforation, formations of the tympanic cavity (thickened mucous membrane, granulations, remnants of the auditory ossicles, etc.) are visible.

If the patient has no complaints about the state of hearing, the perception of whispered speech is examined, the result is recorded for each ear in the form of SR AD and AS 6 m. pipes. If there are complaints of dizziness and balance disorder, the vestibular function is examined and the results are entered in the registration certificate of the functional study of the vestibular analyzer.

The results of the study of hearing in whispered and colloquial speech, as well as tuning forks, are entered into the auditory passport (the scheme for filling out the auditory passport is presented in section 1.4.1).

In the event that there are deviations in the performance of vestibular tests, caloric and rotational tests are additionally performed, and in the presence of balance disorders, stabilometry. The vestibulologist analyzes the results of the vestibulometric study and makes a conclusion.

Passport of the results of a functional study of the vestibular.„otpya and some cerebellar samples

Completing the examination of the patient, the attending physician should analyze the results of studies previously performed on an outpatient basis or in other medical institutions (analyzes, radiographs, ECG, audiograms, consultants' conclusions, extracts from the medical history, etc.). The most significant of these documents are taken into account when establishing a diagnosis along with With results of researches in a hospital.

Clinical diagnosis. It is established after a joint examination of the patient by the attending physician and the head of the department and is formulated in accordance with the nomenclature or generally accepted classification.

Plan of examination and treatment. It is compiled by the attending physician together with the head of the department at the first examination in the hospital. In medical institutions in Moscow, in accordance with the requirements of insurance medicine, when planning diagnostic and treatment procedures, it is necessary to take into account the recommendations of the manual "Medical Standards for Hospital Care" (Moscow, 1997). When assigning additional studies that go beyond the "standards", it is necessary to justify them in the medical history.

The plan indicates the necessary general clinical, biochemical, radiological and special functional (ECG, EEG, REG, dopplerography, angiography, etc.) studies, applied otorhinolaryngological methods (audiological, vestibulometric, etc.); note the necessary consultations of representatives of related specialties, the planned surgical treatment, indicating the method of anesthesia.

Inspection of the head of the department. Confirmation of the clinical diagnosis, agreement with the plan of examination and treatment of the patient, additions.

Preoperative epicrisis. 1. Indicate the surname, name and patronymic (full name), age of the patient, clinical diagnosis, objective signs of a surgical disease (for example, there is a pronounced curvature of the nasal septum in the bone and cartilage region with impaired respiratory function).

The duration of the disease, the frequency of exacerbations, and the ineffectiveness of conservative treatment are noted. Provide the basic data of laboratory and functional studies in preparation for surgery.

They determine the purpose of the operation and its main stages, the proposed method of anesthesia, make a note about the patient's informed consent to the operation, about the psychoprophylactic conversation, and also that the patient was warned about possible complications of the operation. The patient's handwritten signature is required, for children under the age of 15 - the signature of the parents. Indicate the names of the surgeon and assistants. Signature of the curator. Signature of the head of the department.

If the operation is planned with the participation of an anesthesiologist, then before the operation there should be a record of the indicated specialist about the patient's condition and the necessary preparation for anesthesia.

Operation(name, number). The date and time the operation started and ended. Local anesthesia ... (or anesthesia). Consistently note: incision ... separation ... removal ... autopsy ... exposure ... revision under a microscope ... tamponade ... suturing ... bandage ... Mark the blood loss ..., features of the pathological process, complications (if any), the patient's condition after recovery from anesthesia and immediately after surgery. Indicate what material is sent for pathohistological examination. postoperative diagnosis. Appointments.

Surgeon's signature.

Assistant's signature.

All operations (appointments, results, outcomes) are personally controlled by the head of the department, and if necessary, the head of the department or his deputies.

Keeping a diary. In the first 3 days after the operation, the attending physician makes detailed entries in the diary; in severe cases, daily detailed diaries are kept with the notes of the doctor on duty, reflecting the dynamics of the patient's condition during the period when the attending physician was absent. Entries in the diary must contain the notes of the attending physician about the receipt of the results of the performed laboratory and functional studies

with the interpretation of these results. In the diary, the attending physician must also justify all new appointments.

Every 10 days be sure to draw up milestone epicrisis, which briefly reflect the patient's condition, the main results of the examination and treatment (including surgical), indicate a plan for further management of the patient.

If the patient is unable to work for 30 days(taking into account the days of disability before admission to the hospital), then he is sent to Clinical Expert Commission (CEC) to assess the validity and necessity of further extension of the disability certificate.

If the incapacity lasts 4 months it is mandatory to refer the patient to medical and social expert commission (MSEK) to resolve the issue of the advisability of transferring him to disability or the possibility of further extension of the disability certificate (if there are prospects for a cure).

The day before discharge, the head of the department examines the patient, assessing his objective condition, the results of surgical treatment, indicating the functions of the ENT organs, and gives recommendations for further treatment at the place of residence.

Excerpt epicrisis. Surname, initials, was (was) in the ENT department from ... to ... about ... (final diagnosis) ... "..." ... 200 ... an operation was performed ... under ... anesthesia ... (full name of the operation). The operation and the postoperative period without complications (indicate the features of the course of the operation, the main operational findings, the results of histological examination, the features of the postoperative period). At present: a brief objective picture of the operated organ (for example, moderately pronounced reactive phenomena) and function (for example, hearing in the right ear before surgery: SR - at the sink; at discharge: SR - 3 m).

Discharged in a satisfactory condition under the supervision of an otolaryngologist of the district clinic, it is recommended ■ (number of days of observation, nature of therapeutic effects, number of days at home).

Physician's signature.

Signature of the head of the department.

(Deputy chief physician of the hospital for surgery)

At the time of discharge, the attending physician also fills out dropping out cardfrom the hospital.

IN MILITARY MEDICAL INSTITUTIONS

St. Petersburg 2001

The guidelines set out the requirements for the design of the main sections of the medical history in accordance with the provisions of the Fundamentals of the legislation of the Russian Federation on the protection of the health of citizens, the Guidelines for the medical support of the Armed Forces of the Russian Federation in peacetime and other guidelines.

The guidelines are intended for medical personnel of military medical institutions.

The guidelines were developed by the staff of the Military Medical Academy, Candidate of Medical Sciences, Associate Professor, Colonel of the Medical Service M.V. Epifanov, Professor, Doctor of Medical Sciences, Colonel of the Medical Service, V.D. Isakov, Professor, Doctor of Medical Sciences, Colonel of the Medical Service, S.A. Povzun, Colonel of the Medical Service N.D. Polukarov, Professor Doctor of Medical Sciences, Colonel of the Medical Service Yu.S. Polushin, Candidate of Medical Sciences, Associate Professor, Colonel of the Medical Service A.V. Ovchinnikov, Professor Doctor of Medical Sciences V. Yu. Tegza.

I. Introduction ............................................... ................................................. ..................... 1

1.1. General requirements for record keeping in the medical history .............................................. 1

II. Registration of a medical history in the admission department .................. 1

III. Records in the medical history during the initial examination of the patient in the medical department ................................................. ....................... 1

3.1. Physician's record ............................................................... ........................................... 1

IV. Keeping a medical history in the medical department .............................................. 1

4.1. Diary entry .............................................................. ................................................. 1

4.2. Record of the round of the head of the department (clinic) .............................................. .... 1

4.3. Clinical Recording .................................................................................. ................................ 1

4.4. Council recording .............................................................. ................................................ 1

4.5. Research records .................................................................. ............................................ 1

4.6. Arrangement of surgical interventions .............................................................. ............ 1

4.6.1. Preoperative conclusion of an anesthesiologist .............................................. 1

4.6.2. Preoperative epicrisis .................................................................. ...................... 1

4.6.3. Operation log .................................................................. ..................................... 1

4.6.4. Registration of anesthetic support for surgical interventions 1

4.7. Record keeping in the intensive care unit 1

4.8. Registration of transfusions of blood and its components .............................................. 1

V. Registration of expert decisions .................................................. ............... 1

5.1. Expert opinions of medical specialists ............................................................... .... 1

5.2. Registration of submission to the VVK (MSEK) .............................................. ......... 1

5.3. Making a submission to the clinical expert commission .............................. 1

VI. Completion of the medical history .............................................................. ....................... 1

6.1. Discharge summary .............................................................. ................................................ 1

6.2. Translation Epicrisis .................................................................. ............................................. 1

6.3. Posthumous epicrisis .................................................................. ............................................ 1

6.4. Making the title page of the medical history .............................................................. . 1

VII. Formation of the relationship between the doctor and the patient .............................. 1

VIII. Literature................................................. ................................................. ......... 1

I Introduction

The medical history is the main medical document on the condition and treatment of the patient, which is maintained in the hospital for each patient. It has practical, scientific and legal significance. The practical significance of the medical history is to ensure continuity in the examination and treatment of the patient, scientific - in the ability to analyze and summarize the results of the examination and treatment of various categories of patients. The medical history is also an important legal document that records the patient's condition, the presence of a particular pathology, which may be important for establishing fitness for military service, disability, a causal relationship with the injury, the legitimacy of insurance payments, and also allowing medical management, as well as in disputable cases, and the justice authorities to assess the adequacy of medical care provided to the patient.

A strict sequence of presenting the information obtained during the examination of the patient disciplines clinical thinking, ensures the continuity of diagnosis and treatment. Records of the dynamics of the disease, a reliable reflection of the effect of certain therapeutic measures allow timely correction of the treatment program.

The attending physician is legally responsible for the correctness and accuracy of the entries in the medical history.

These guidelines will help medical specialists of military medical institutions improve the maintenance and execution of medical histories, which will undoubtedly contribute both to the improvement of the treatment and diagnostic process and to the improvement of the legal relationship between the parties involved in the organization and provision of medical and medical and social assistance to military personnel. and members of their families.

I.1. General requirements for keeping records in the medical history

The medical history is the main document of the personal medical records of patients undergoing inpatient treatment. It consists of a permanent part and a set of inserts: a medical prescription record sheet, a temperature sheet, an intensive care card, an anesthetic benefit card, a surgical operation protocol, an extracorporeal detoxification card, a gynecological examination card, and a pregnancy termination card. The inserts are filled out only for those patients who underwent certain procedures, and are subsequently pasted into the medical history. All entries in the medical history are made in blue (black, purple) ink or with a ballpoint pen. All entries in the medical history must be accurate, complete and consistent. Records must be legible, abbreviations and abbreviations that make it difficult to understand the text or allow double interpretation are not allowed. Sheets with text printed on a typewriter or printer can be pasted into the medical history, especially in cases where the text is written in several copies (for example, presentation at the VVK and a certificate of illness, protocol of surgery, etc.). All forms of protocols of diagnostic and therapeutic manipulations and procedures, operations, laboratory tests pasted into the medical history must contain identification features (surname and initials of the patient, case history number, name or number of the department, ward, study number).

All records are kept by a medical worker in his own hand and are confirmed by a signature indicating the position, military rank, initials and surname. All entries are made in chronological order with date (and, if necessary, time). Correction of incorrect (erroneous) entries is allowed only by carefully crossing out with the mark "the entry is erroneous" so that the erroneous entry remains readable. Corrections are confirmed by the signature of the doctor. It is not allowed to stick incorrect entries or paint over them with ink. Spelling errors can be corrected using a "stroke-corrector".

If any additional data is found in chronological order, a separate entry is made, preceded by the phrase “In addition to the medical history (diary entry from “__” ____20__, etc.)”. It is advisable to illustrate the detected pathology, especially with its multiplicity, with diagrams, drawings, photographs, a schematic representation of non-standard operations that make the information in the medical history more accessible for perception.

II. Making a medical history in the admissions department

The medical history is drawn up by the nurse of the admission department for each patient admitted to the admission department of a military medical institution on the basis of relevant documents or who applied independently. On the title page of the medical history, the nurse records the following data:

1) The name of the military medical institution.

2) Date and time of admission of the patient to the emergency department.

3) Surname, name, patronymic of the patient.

4) Date, month and year of birth (age) of the patient, gender.

5) Name, series and number of the patient's identity document.

6) The postal address of the place of residence (upon registration), as well as the postal address of the place of actual (including temporary) residence of the patient, if they are different.

7) Last name, first name, patronymic, postal address and telephone number of the next of kin.

8) What contingent does the patient belong to (serviceman of the Republic of Armenia or other departments, cadet, cadet, Suvorov, Nakhimov, pensioner of the Ministry of Defense of the Russian Federation, family member of a serviceman of the Republic of Armenia or a pensioner of the Ministry of Defense of the Russian Federation, officer's widow, etc.). For military personnel, the military rank, number and address of the military unit, year and month of the conclusion of the contract (conscription) for military service are indicated.

9) Place of work, specialty, position.

10) Who sent the patient. The name and number of the document on the basis of which the patient was admitted to the emergency department. The name of the insurance company that issued the compulsory or voluntary health insurance policy and the policy number.

11) The diagnosis with which the patient was referred (from the accompanying documents).

12) The presence of a food certificate, a medical book, a disability certificate, their number is noted.

On the second page of the medical history, the nurse of the admission department notes body temperature, blood pressure, pulse rate, body weight and height of the patient, chest circumference (at rest).

The doctor on duty at the admissions department, indicating the time and date of examination of the patient, records the results of the clinical study (complaints; anamnesis of the disease indicating the circumstances of the injury, the amount of care at the pre-hospital stage and the method of transporting the patient to a military medical institution; basic objective data, necessarily indicating the severity of the patient's condition ) and the diagnosis of the detected disease. The revealed defect of the prehospital period is recorded with an indication of its nature and main causes, as well as the serial number by which it is registered in the "Journal of Defects".

In the column of appointments, the doctor on duty writes down urgent diagnostic and therapeutic measures that must be performed in the admission department. The volume of emergency (including resuscitation) care provided in the admission department must be recorded by the doctor on duty with an indication of the time. The doctor of one of the medical departments, examining the patient in the admissions department in order to clarify the diagnosis and determine indications for hospitalization, writes down the results of the examination, the diagnosis and the decision on hospitalization on the following pages of the case history. In complex diagnostic cases, when the decision on hospitalization was made with the participation of specialist doctors, a record of a joint examination or a record of the council can be issued.

After the decision on hospitalization is made, the doctor on duty indicates on the title page the name of the department to which the patient is sent, and in the appointment column - the type of sanitization, the method of delivering the patient to the department, the regimen and diet. The nurse of the admission department marks the serial number of the medical history on the title page, pastes the referral and other accompanying documents into the history, as well as an inventory of the documents, money and valuables deposited, and an inventory of the clothes handed over. The title page of the medical history is signed by the patient about familiarization with the daily routine and the rules of behavior for patients.

There should be no empty columns on the title page. In the absence of certain information, it is indicated, for example, “Unknown man, 40-45 years old”, “entered without documents”, etc. In the event that the missing data is subsequently clarified, the preliminary entry is crossed out and a new one is made next to it.

For objects found in patients that could serve or were instruments of simulation, self-mutilation or artificial disease (medicines, syringes, needles, reagents, etc.), an act of their seizure is drawn up. It indicates when and under what circumstances they were discovered and seized, their number, and a brief description. The act is signed by the persons who took part in the discovery and seizure of objects, a copy of it is pasted into the medical history or an appropriate entry is made in it, certified by the signature of the doctor.

If hospitalization is refused, the doctor on duty records in the history the reason for the refusal (lack of evidence, refusal of the patient), recommendations to the patient and the doctor of the military unit (polyclinic), indicates where the patient was sent and what document was issued to him (certificate, entry in the medical book). The serial number on such a case history is not put.

If a patient is admitted in a state of clinical death, from which it was not possible to bring him out, a medical history is also drawn up for him, which indicates the nature of the identified pathology, the volume and duration of resuscitation, and a diagnosis that can be made in a presumptive form.

When a patient is placed in the diagnostic ward of the admission department, the doctor on duty draws up an initial record of the attending physician and keeps a medical history in accordance with sections III and IV of these recommendations.

In cases of injury (poisoning), on the first sheet of the medical history there should be a note from the nurse on duty (doctor on duty) about the date and time of the transmission of the telephone message to the military unit (police department at the victim's place of residence) indicating the name and position of the person who received the message.