Currently, one of the priority areas of healthcare is the development of primary health care and the implementation of the national project “Health”. This methodological manual reflects the system for constructing the main direction of providing primary health care to the population - outpatient care: nomenclature and principles of organization, structure and performance indicators of the clinic, the role, tasks and organization of the work of the primary care doctor in the process of shaping the health of the population.

Particular attention is paid to the dispensary method of observation, organization of the work of the main departments of the clinic, and inpatient-substituting forms of medical care for the population.

When compiling the manual, orders of the Ministry of Health and Social Development of the Russian Federation were used. As a practical task, situational tasks and test control questions developed by the department staff were proposed.

This teaching aid can be used for classroom and independent work and is intended for medical academy students, residents and health care managers.

I. INTRODUCTION

In the early 1970s, there was an orientation in the activities of the World

health care organizations on the problem of primary health care

as one of the main directions of improving public health.

In accordance with the “Fundamentals of the legislation of the Russian Federation on the protection of the health of citizens,” put into effect by the Resolution of the Supreme Council of the Russian Federation of July 22, 1993, primary health care (PHC) is defined as the main link in the provision of medical care to the population.

Primary health care is a set of medical and sanitary-hygienic measures carried out at the first (primary) level of contact of the population with health services.

To ensure accessibility and quality of primary medical care for the population and improve the working conditions of medical workers, the main directions of the priority national project “Health” were developed: strengthening primary health care, developing prevention, clinical examination of high-tech types of medical care. In recent years, a phased introduction of such an outpatient service as a general medical practice (especially in rural areas) has been carried out, which makes it possible to ensure continuity and continuity of observation of patients.

The leading link in the primary health care system is outpatient care.

The main goal of this manual is to prepare for independent work in outpatient clinics. To do this, students are given the following tasks:

1. Study the principles of organizing outpatient care.

2. Familiarize yourself with the nomenclature of outpatient clinics.

3. Master the tasks and functions of outpatient services.

4. Know the structure and basic documentation of the clinic.

5. Master the skills of working with primary medical documentation of the clinic.

6. Be able to analyze the performance indicators of the clinic.

7. Master the methodology for calculating and assessing the quality of the main activities of the clinic.

The duration of the topic study is 6 hours and includes: introduction to the theoretical foundations of organizing outpatient care (principles and objectives of the clinic, its structure and main functions), independent work, written solution of situational problems, test control, discussion of the abstract message and summing up the lesson. .

The topic being studied provides an understanding of modern problems in organizing outpatient care in the Russian Federation and provides an opportunity to acquire the skills necessary for a healthcare organizer in practical activities when assessing and analyzing the work of a clinic.

II. GENERAL PRINCIPLES OF ORGANIZING OUTPATIENT CLINIC SERVICES

Nomenclature of outpatient clinics:

Outpatient clinic.

Clinics, including:

Urban, including children's;

Central District;

Dental, including children's;

Consultative and diagnostic, including for children;

Psychotherapeutic;

Physiotherapeutic;

Rehabilitation treatment.

The basic principles of outpatient care are:

Participation;

Availability;

Preventive focus (dispensary method of work);

Continuity and phasing of treatment.

The organization of outpatient care is based on the local principle, i.e. an institution is assigned a certain territory, which in turn is divided into territorial sections. The local medical service is the main form of organizing primary health care for the population at the prehospital stage. Each site is served by a local doctor (therapist, pediatrician, obstetrician-gynecologist, general practitioner (family doctor) and a paramedical worker. In medical units, the provision of medical care to employees of industrial enterprises is carried out according to the principle of shop division.

at the therapeutic site - 1,700 adults aged 18 years and older;

in the pediatric section - 800 children aged 0 - 17 years inclusive;

in the obstetrics and gynecology department - 2000 - 2500 female population;

at the general practitioner's site - 1,500 adults aged 18 years and older;

in the family doctor's area - 1,200 adults and children.

The local service principle allows:

1. Patients should be treated by one doctor, and the doctor should systematically observe the same patients.

2. Know the working and living conditions of the population.

3. Study the morbidity of the population, identify patients in need of medical examination.

4. Carry out anti-epidemic and preventive measures more effectively.

5. Systematically increase the sanitary and cultural level of the population.

Compliance with the local service principle is possible under the following conditions:

Clear definition of the boundaries and population of areas;

Staffing of regular positions of local doctors;

Eliminating the reasons for the turnover of doctors at the sites;

Establishing work schedules for local doctors that are convenient for the population (sliding schedules);

Proper organization of the registry work.

III. DISPANSERIZATION - THE BASIS OF PREVENTIVE WORK OF OUTPATIENT POLYCLINIC INSTITUTIONS

An important feature of outpatient care is the organic combination of therapeutic and preventive work in the activities of medical personnel. The specific expression of preventive work consists in the widespread use by doctors of outpatient clinics, especially local therapists, of the dispensary method.

The dispensary method is a method of active dynamic monitoring of the health status of the population (healthy and sick), and timely implementation of preventive measures.

The objectives of the dispensary method of service are:

1. Prevention of diseases (primary or social-hygienic prevention).

2. Preserving the ability of patients to work, preventing complications, exacerbations, crises (secondary or medical prevention).

3. Maintaining quality of life through therapeutic measures for people with disabilities, cancer patients, AIDS patients, etc. (tertiary prevention).

To accomplish these tasks, the dispensary method involves carrying out a certain system of measures:

1. Formation of contingents (healthy and sick) for dispensary registration, dynamic observation and carrying out planned therapeutic, health-improving and preventive measures among them.

2. Assessing the health status of each person and providing systematic dynamic medical supervision.

The selection of patients for clinical examination should be carried out in the earliest stages of the disease, when therapeutic and preventive measures are most effective.

Methods of selection for dispensary registration:

1. Current appeal to local general practitioners and medical specialists.

2. Preventive medical examinations.

Preventive medical examination is one of the forms of active medical care for the population in order to identify diseases in the initial stages and carry out treatment and preventive measures.

The following types of preventive medical examinations are distinguished:

Preliminary - medical examinations upon entry to work or study in order to determine whether health meets the requirements of the profession or training, as well as to identify diseases that may worsen or progress in conditions of work with occupational hazards or in the process of study;

Periodic medical examinations - a systematic examination depending on working conditions and risk factors in order to identify early signs of occupational diseases or poisoning, as well as diseases that are not etiologically related to the profession, but in which continued contact with these occupational hazards poses a danger;

Targeted preventive medical examinations are medical examinations undertaken to identify certain

diseases at an early stage (tuberculosis, neoplasms, glaucoma, diabetes mellitus, cardiovascular diseases, etc.) and covering various groups of organized and unorganized population.

The following are subject to dispensary observation:

A. Contingent of healthy individuals:

2) teenagers, conscripts;

3) workers in workshops and professions with hazardous working conditions;

4) citizens entitled to receive state social assistance;

5) pregnant women.

B. Patients (including persons entitled to receive state social assistance).

The following groups of dispensary observation are distinguished:

Dispensary group I - healthy individuals, i.e. those who do not complain, and their medical examination does not show the presence of painful abnormalities (they do not have chronic diseases and are fully able to work).

Dispensary group II - practically healthy individuals who have one or another chronic disease that does not affect the functions of vital organs and ability to work, as well as individuals with an increased risk of disease who need observation.

III dispensary group - chronically ill persons with compensated forms of diseases, in whom the disease proceeds easily, without any particular impairment of body functions.

IV dispensary group - patients with chronic diseases in the subcompensation stage, in whom the disease is accompanied by moderate dysfunction of individual organs and systems and there are frequent exacerbations and long-term disability.

V dispensary group - patients at the stage of clinical decompensation, i.e. those in whom the disease occurs with persistent and severe impairment of body functions and is accompanied by prolonged and complete disability.

After determining the dispensary observation group, an individual plan of preventive and therapeutic measures is developed for each person examined, including medical recommendations on work, rest, rational nutrition, and, if necessary, drug treatment, exercise therapy, massage, physiotherapy, diet, health improvement in a dispensary and sanatorium are prescribed.

An individual follow-up plan includes the following sections:

Frequency of observation, frequency of necessary laboratory and other studies, consultations with other specialists;

Specialized outpatient, inpatient treatment, therapeutic exercises, physiotherapeutic treatment, stay in a dispensary, sanatorium treatment, etc.;

Study of working and living conditions;

Carrying out social and health activities (rational employment, diet, social and legal assistance, etc.).

At the end of the year, the doctors of the clinic draw up a staged epicrisis for each dispensary patient, which provides an assessment of the patient’s health status and the effectiveness of treatment and preventive measures.

Clinical examination of patients with tuberculosis, skin and venereal diseases, cancer and neuropsychiatric diseases is carried out in specialized dispensaries.

IV. POLYCLINIC IS A LEADING HEALTH CARE INSTITUTION IN PROVIDING PRIMARY HEALTH CARE TO THE POPULATION

Among outpatient clinics, the main ones are the clinic and the outpatient clinic.

A polyclinic is a multidisciplinary medical and preventive institution that provides primary qualified specialized medical care to visiting patients or patients at home, and also carries out a set of therapeutic and preventive measures to treat and prevent the development of diseases and their complications.

An outpatient clinic is usually organized in rural areas and differs from a clinic in the level of specialization and scope of activity. The outpatient clinic, as a rule, provides appointments for the main specialties: therapy, surgery, obstetrics-gynecology, pediatrics.

Clinics are divided into:

On the organization of work:

Combined with a hospital;

Unintegrated (independent);

By territorial basis:

Urban;

Rural;

According to the profile of medical care:

Adult population;

Children's population;

Workers of industrial enterprises;

Specialized (dental, physiotherapeutic, psychotherapeutic, rehabilitation treatment).

Objectives of the clinic

1. Providing qualified specialized medical care to the population of the serviced area directly in the clinic and at home.

2. Organization and implementation of a set of preventive measures among the population of the serviced area and employees of attached industrial enterprises, aimed at reducing morbidity, disability and mortality.

3. Organization and implementation of clinical examination of the population (healthy and sick).

4. Organization and implementation of events for sanitary and hygienic education of the population, promotion of a healthy lifestyle.

Clinic structure

The clinic consists of 3 parts: management, medical part and economic service.

1. Clinic management.

The work of the independent clinic is headed by the chief physician. If the clinic is part of a hospital, then the deputy chief physician for the clinic is in charge of the clinic. The chief physician manages the activities of the institution and is responsible for the quality of treatment and preventive care, as well as organizational, administrative, economic and financial activities. The chief physician carries out the selection and placement of medical and administrative personnel, is responsible for their work, rewards well-performing initiative employees and brings to disciplinary action violators of labor discipline, carries out personnel placement, organizes advanced training for doctors and paramedical personnel, prepares a reserve of managers departments, establishes work schedules, approves staff work schedules, etc.

The deputy chief physician of the clinic for medical affairs is responsible for the treatment and preventive activities of the institution. He organizes and monitors the correctness and timeliness of examination and treatment of patients at the clinic and at home, monitors the constant introduction into practice of modern, most effective methods of prevention, diagnosis and treatment of patients. He ensures continuity in the examination and treatment of patients between the clinic and hospitals, the organization of hospitalization of patients, manages all preventive work, etc.

The deputy chief physician of the clinic for the examination of temporary disability is responsible for the implementation of clinical expert activities.

In addition to administration, hospital management includes accounting, office, medical statistics office, archive, library, etc. (Fig. 3).

2. Medical part

The structure of the medical part of the clinic is determined by its capacity and the size of the population served (Fig. 4) and includes a registry, main treatment and preventive rooms (offices of local therapists, offices of specialists); department (office) of rehabilitation treatment; day hospital; prevention department; auxiliary treatment and diagnostic units (x-ray room, laboratory, functional diagnostics department, endoscopy room, etc.), self-supporting departments and departments of additional paid services, health centers at industrial enterprises.

In addition, a department of medical and social rehabilitation and therapy, nursing services, outpatient surgery centers, and medical and social assistance centers can be deployed at the clinics.

3. Housekeeping service. The administrative and economic part includes a garage, laundry, boiler room, storage rooms and other units. All administrative and economic work is supervised by the deputy chief physician for administrative and economic affairs, whose responsibilities include: maintaining the building, premises, territory, economic communications, providing the institution with vehicles, fuel and solving other economic problems.

The main areas of work of the clinic

To carry out its tasks, the city clinic organizes and conducts the following events:

1. Providing first (pre-hospital, medical) and emergency medical care to patients with acute diseases, injuries, poisoning and other emergency conditions.

2. Early detection of diseases, qualified and full examination of sick and healthy people, provision of medical care to the population, both at an outpatient appointment in a clinic and when providing care at home.

3. Timely hospitalization of persons in need of inpatient treatment.

4. Rehabilitation treatment of patients.

5. All types of preventive examinations (preliminary, periodic, targeted).

6. Medical examination of the population.

7. Anti-epidemic measures.

8. Examination of temporary disability of patients, referral for medical and social examination of persons with signs of persistent disability.

9. Establishment of medical indications for spa treatment.

11. Sanitary educational work to promote a healthy lifestyle.

12. Accounting and analysis of the activities of personnel and departments of the clinic.

13. Activities to improve the qualifications of doctors and nursing staff.

V. ORGANIZATION OF WORK OF STRUCTURAL DIVISIONS OF THE POLYCLINIC

1.Registration

The reception desk plays a significant role in organizing services for the population in the clinic.

The main tasks of the registry are:

1. Organization of preliminary and urgent registration of patients for an appointment with a doctor, both when they directly contact the clinic and by telephone;

2.Distribution of patient flow by type of care in order to create an even workload for doctors;

3. Ensuring timely selection and delivery of medical documentation to doctors’ offices, proper maintenance and storage of the clinic’s file cabinet.

The registry of the city clinic has: a help desk, workstations for receiving and registering doctor's home calls, a room for storing and selecting outpatient medical records, a room for processing medical documents, and a medical archive. In addition, a self-recording room (table) may be provided.

The document that allows you to plan the rational work of the clinic is the “Coupon for an appointment with a doctor” f.025-4/u-88. Vouchers for doctor's appointments are prepared in advance, based on doctors' work schedules.

The most rational type of registry is a centralized registry, which provides for maintaining a single outpatient card for all specialties and offices.

2. Prevention department

Can be organized in city clinics serving more than 30 thousand. people, and includes the following rooms:

Pre-medical appointment,

Female examination room,

Cabinet of health education and hygienic education,

Office for organizing and monitoring medical examinations, maintaining a centralized file index of persons registered with medical examinations.

The main objectives of the prevention department are:

1.Early identification of patients and persons at increased risk of diseases.

2.Organization and control of medical examination.

3.Organization and implementation of preventive vaccinations for adults and adolescents.

4.Development of an action plan for disease prevention in the clinic’s service area.

5. Promotion of a healthy lifestyle.

To carry out these tasks, the prevention department of the city clinic organizes and carries out the following activities:

Referring all patients who visited the clinic for the first time in a given year to preventive fluorography, and women to the examination room for the purpose of early detection of cancer and precancerous diseases;

Identification of persons with an increased risk of disease when they contact the prevention department;

Registration of healthy and sick people under dispensary observation, assistance to doctors in organizing examinations of persons under dispensary observation

Preparation and transfer of medical documentation to medical specialists for identified patients and persons at increased risk of the disease for additional examination, clinical observation and treatment;

classes for patients with various diseases (arterial hypertension, bronchial asthma, diabetes, etc.)

3. Organization of the work of a local physician-therapist

The work of a local therapist is carried out according to a schedule approved by the head of the institution, which provides for fixed hours of outpatient appointments, time for providing care at home, preventive and other work.

The working day of a general practitioner at the site consists of seeing patients at the clinic (4 hours) and serving patients at home (2 hours). Every month, the local doctor is allocated 12 hours for preventive work, including 4 hours for health education. The optimal workload for 1 hour of work of a local therapist is 4 - 5 people at a clinic appointment and 2 people when providing care at home.

Responsibilities of a local doctor

1. Forms a medical (therapeutic) area from the population attached to it (see Appendix 2 “Passport of the medical (therapeutic) area”).

2. Provides sanitary and hygienic education, advises on the formation of a healthy lifestyle; carries out preventive measures to prevent and reduce morbidity, identify early and latent forms of diseases.

3. Studies the needs of the population he serves for health-improving activities and develops a program for carrying out these activities.

4. Carry out dispensary observation of patients, including those entitled to receive a set of social services, in the prescribed manner.

5. Organizes and conducts diagnostics and treatment of various diseases and conditions, including rehabilitation treatment of patients in an outpatient setting, day hospital and home hospital.

6. Provides emergency medical care to patients in case of acute diseases, injuries, poisoning and other emergency conditions in an outpatient setting, day hospital and home hospital.

7. Refers patients for consultations with specialists, including for inpatient and rehabilitation treatment for medical reasons.

8. Organizes anti-epidemic measures and immunoprophylaxis in the prescribed manner.

9. Conducts an examination of temporary disability in the prescribed manner and draws up documents for referral to a medical and social examination.

10. Issues a conclusion on the need to refer patients for medical reasons to sanatorium-resort treatment.

11. Interacts with medical organizations of state, municipal and private healthcare systems, medical insurance companies, and other organizations.

12. Organizes, together with the social protection authorities, medical and social assistance to certain categories of citizens: single, disabled, elderly, chronically ill, in need of care.

13. Manages the activities of nursing staff providing primary health care.

14. Maintains medical documentation in the prescribed manner, analyzes the health status of the assigned population and the activities of the medical site.

Doctors of narrow specialties play an important role in organizing medical care for the population. To perform the main tasks, the specialist doctor ensures the implementation of preventive measures, early detection of diseases, qualified and timely examination and treatment of patients of his profile, examination of temporary disability, continuity between the hospital and the clinic in the treatment of patients, timely hospitalization of patients according to indications, dispensary observation of patients own profile, high-quality maintenance of medical records.

4. Department (office) of rehabilitation treatment

The rehabilitation treatment room is organized in a city clinic serving at least 30 thousand people to treat patients with cardiovascular diseases, consequences of injuries, orthopedic, neurological and other diseases.

Patients are admitted for rehabilitation treatment by referral from the heads of the structural units of the clinic.

The office accepts patients after the end of the acute period who need a special complex of rehabilitation treatment with the following diseases:

Myocardial infarction in the scarring stage, chronic ischemic heart disease, previous heart surgery;

Brain stroke in the recovery period;

Spinal fractures without dysfunction of the spinal cord, fractures of the pelvis, shoulder girdle, upper and lower extremities, joint injuries, arthritis and arthrosis;

Motor and speech disorders after operations for tumors and vascular diseases of the brain;

Cervicothoracic and lumbosacral radiculitis, including discogenic, with frequent and prolonged exacerbations in the phase of beginning restoration of motor functions, reduction of pain.

To carry out rehabilitation treatment and monitor the condition of patients during the treatment period, the office uses the necessary diagnostic and treatment and auxiliary departments of the clinic (physiotherapeutic, physical therapy, etc.).

The main objectives of the rehabilitation treatment room are:

1. Timely start of rehabilitation treatment of patients and ensuring continuity, continuity, consistency, phasing in the organization and implementation of the treatment program.

2. Providing a differentiated approach to methods and means of restorative treatment for various groups of patients.

In accordance with these tasks, the rehabilitation treatment room is assigned the following functions:

Drawing up an individual program of rehabilitation treatment for the patient and its implementation using modern methods and means of rehabilitation treatment;

Involving the necessary specialists of the clinic for consultation, establishing relationships and continuity with other departments of the clinic.

5. Day hospital

A day hospital is a structural unit of treatment and preventive institutions, including outpatient clinics, and is intended to carry out preventive, diagnostic, therapeutic and rehabilitation measures for patients who do not require round-the-clock medical supervision, using modern medical technologies in accordance with the standards and protocols for patient management .

The purpose of the day hospital is to improve the organization and quality of medical care in an outpatient setting, as well as to increase the economic efficiency of the activities of medical institutions.

The main objectives of the day hospital are:

1. Carrying out comprehensive preventive and health measures for people at risk of increased morbidity, incl. professional, as well as long-term and frequent illness.

2. Conducting complex and complex diagnostic studies and treatment procedures related to the need for special training of patients and short-term medical observation after carrying out the specified treatment and diagnostic measures.

3. Selection of adequate therapy for patients with a newly diagnosed disease or chronic patients when the severity of the disease changes.

4. Conducting a comprehensive course of treatment using modern medical technologies for patients who do not require round-the-clock medical supervision.

5. Implementation of rehabilitation and health complex course treatment for sick and disabled people, pregnant women.

6. Conducting an examination of the state of health, the degree of disability of citizens and resolving the issue of referral for a medical and social examination.

The structure of a day hospital may include:

Wards equipped with the necessary equipment and supplies;

Treatment room;

Surgical office with small operating room;

Room for medical personnel;

Other rooms by decision of the management of the medical institution.

To carry out the functions of a day hospital, diagnostic, treatment, rehabilitation and other units of the medical and preventive institution in whose structure it was created can be used.

In day hospitals, patient care is carried out by the attending physician (local therapist, pediatrician, obstetrician-gynecologist, general practitioner and other medical specialists). If necessary, appropriate consultant doctors are involved. For patients who do not require hospitalization, a hospital at home can be organized as part of the clinic. The operating hours of a hospital at home are determined by the head of the medical institution in accordance with the needs of the population for this type of care.

An important section of the clinic’s work is the recording and analysis of statistical data characterizing the activities of the clinic. In all medical and preventive institutions, current accounting documentation, unified for institutions of the same type, is maintained, on the basis of which state statistical reporting data is generated, and monitoring of the provision of primary health care in health care institutions of the constituent entities of the Russian Federation is carried out.

VI. POLYCLINIC PERFORMANCE INDICATORS

1. General performance indicators of the clinic

1.1. Average population in the area:

Population in the service area of ​​the clinic

Number of medical sites

1.2. Staffing level of the clinic, (%):

Number of occupied medical positions x 100

Number of full-time medical positions

The optimal staffing level of the clinic should be 100%

1.3. Area of ​​service provided to the population by therapists (pediatricians) in the clinic, (%):

Number of visits to local doctors by residents of their areas x 100

Total number of visits to local doctors

The indicator characterizes compliance with the principle of local service to the population when visiting doctors in the clinic. With proper organization of the work of local doctors, this figure is in the range of 85-90%

1.4. Locality of service to the population by therapists (pediatricians) at home

The indicator characterizes the degree of compliance with the principle of local service to the population at home. This figure is in the range of 90-95%. A decrease in the rate is observed during influenza epidemics.

1.5. Implementation of the plan for preventive medical examinations of the population, (%):

Persons subject to prophylaxis were examined. medical inspection x 100

Number of persons subject to prophylaxis. medical inspection according to plan

This figure should be close to 100%.

1.6. Frequency of diseases (prevalence) according to preventive medical examinations (per 100 examined persons):

Number of diseases identified

during preventive medical examinations x 100

Number of persons examined during preventive

medical examinations (total)

2. Clinical examination indicators

2.1. Scope of clinical examination

2.1.1. Population coverage with medical examination (per 1000 people):

Number of people under

dispensary observation during the year x 1000

Total population served

2.1.2. Medical examination coverage of healthy, practically healthy and sick people.

2.1.3. Coverage of patients with dispensary observation (per 100 registered patients)

2.1.4. Completeness of early coverage (timeliness of registration at the dispensary),

2.2. Quality of clinical examination

2.2.1. Compliance with the terms of clinical examinations (scheduled observation):

2.2.2. Completeness of coverage of patients with laboratory, X-ray and other types of studies (for each nosological form of disease), (%):

2.2.3. Completeness of medical and recreational activities (sanatorium-resort treatment, dietary nutrition, preventive hospitalization, anti-relapse treatment, employment, etc.),

2.3. Efficiency of clinical examination

The effectiveness of clinical observation should be assessed separately in three groups:

Healthy;

Practically healthy (persons who have had acute illnesses)

Patients with chronic diseases.

The criterion for the effectiveness of clinical examination of healthy people (dispensary observation group I) is the absence of diseases, preservation of health and ability to work (no transfer to the sick group).

The criterion for the effectiveness of medical examination of persons who have suffered acute illnesses (group II of clinical observation) is complete recovery and transfer to the healthy group.

The criterion for the effectiveness of clinical examination of persons suffering from chronic pathology (III group of clinical observation) is stable remission (absence of exacerbations of the disease).

2.3.1. Removed from dispensary registration due to illness (i.e. transferred to the group of practically healthy people)

Number of persons transferred from Group III

dispensary observation for recovery

(improvement) to the group of practically healthy x 100

Number of people under dispensary observation

2.3.2. Frequency of diseases in a group of healthy individuals under dispensary observation

Number of registered diseases per year x 100

Number of healthy persons registered as "D"

2.3.3. Morbidity with temporary disability (in cases and days) for specific nosological forms for which patients were taken under dispensary observation (per 100 dispensaries):

Number of cases (days) of morbidity for a given disease

for those under dispensary observation in the reporting year x 100

Number of people under dispensary observation with this disease

2.3.4. Frequency of relapses, exacerbations and crises

Number of relapses, exacerbations and crises x 100

Number of dispensary patients

2.3.5. Indicator of primary disability per year (per 1000 persons under dispensary observation):

Number of persons recognized as disabled for the first time in a given year

for this disease are under dispensary observation x 1000

Number of people under dispensary observation during the year for this disease

2.3.6. Mortality rate of persons under dispensary registration (per 1000 persons under dispensary observation):

Number of deceased dispensary patients x 1000 Total number of those under dispensary observation.

22.09.2017			12 – 20 – 403		Heads of medical organizations To the directors of the branches of the “TFOMS of the Volgograd Region” Heads of CMO
On the application of tariffs when providing outpatient medical care

The state institution “Territorial Compulsory Medical Insurance Fund of the Volgograd Region” explains following a video conference meeting on the organization and payment of medical care in an outpatient setting.

Based on the Tariff Agreement in the field of compulsory health insurance of the Volgograd region for 2017, per unit of payment for medical care, including emergency care provided on an outpatient basis, the following are accepted:

Medical visits (for preventive purposes, for other purposes, when providing emergency medical care),

Visits to a paramedic (midwife) conducting an independent appointment (for preventive purposes, for other purposes, when providing emergency medical care),

Treatment (completed case, including during medical rehabilitation, during dispensary observation),

A completed case of medical examination of certain groups of the adult population,

Completed case of conducting preventive medical examinations of the adult population,

A completed case of medical examination of orphans and children in difficult life situations staying in inpatient institutions,

A completed case of medical examination of orphans and children left without parental care, including those adopted, taken under guardianship (trusteeship) in a foster or foster family,

Completed case of medical examinations of minors,

Visits to the health center,

Treatment and diagnostic services (computed tomography, magnetic resonance imaging, laboratory and diagnostic),

Per capita funding standard.

A visit is a patient’s contact with a doctor (except for doctors of paraclinical specialties), paramedical personnel conducting independent appointments, in an outpatient clinic organization (unit), as well as at home, including a set of necessary preventive, therapeutic and diagnostic services, with subsequent registration in medical record of an outpatient (diagnosis, prescription of examination, treatment, records of dynamic observation and other records based on observation of the patient).

TO visits for preventive and other purposesshould include:

Visits regarding examinations upon admission to study, to preschool institutions, when sending children to summer health camps, sanatoriums, boarding houses and other children's health organizations; inspections of contingents subject to periodic inspections; examinations of the population during medical examinations, examinations when deciding on the issue of preventive vaccinations;

Visits to pregnant women during normal pregnancy, visits to women who have applied for contraceptive use, etc.;

Patronage visits to healthy children in the first year of life;

Visits to health centers;

Visits in connection with obtaining certificates and other medical documents;

One-time visits regarding illness (injury, other condition);

Visits in connection with the registration of a sanatorium-resort card, registration of referrals for medical and social examination;

Consultations regarding illness (injury, other condition);

If, during a preventive examination, the doctor only suspected a disease, but did not make a diagnosis, and referred the patient to an appropriate specialist to establish a diagnosis, this visit to the doctor who conducted the examination should be taken into account as made for preventive purposes.

As part of each visit carried out at the expense of compulsory health insurance, medical organizations are required to keep records directions

An appeal regarding a disease is a completed case of treatment of a disease (injury or other condition) by a doctor of one specialty, a paramedic (midwife) with a frequency of at least two visits for one disease.

An application for medical rehabilitation on an outpatient basis is a complete case of medical rehabilitation from doctors of several specialties and a set of treatment and diagnostic procedures in accordance with regulatory documents regulating the provision of medical rehabilitation.

An appeal as a complete case consists of initial and repeat visits regarding the disease, treatment, diagnostic and rehabilitation measures, which result in recovery, improvement, referral of the patient to a day hospital, for hospitalization in a 24-hour hospital, for a medical and social examination, etc. P.

To appeals should also include the totality of visits regarding the pathology of pregnancy, visits regarding anomalies of refraction and accommodation (except for visits regarding presbyopia of persons aged 40 years and older), anomalies of speech, voice and hearing, etc.

To appeals should also include carrying outdispensary observationas part of the provision of primary health care to patients with chronic non-communicable diseases and patients at high risk of developing them, includingvisits within a month.

At the same time, cases of treatment (treatment for therapeutic purposes) of one patient by different specialists (for example: a therapist and a physiotherapist; a paramedic and a traumatologist; a cardiologist and an ophthalmologist, etc.) can be counted. When treating one pathology by doctors of different specialties, one of the specialists acts as the attending physician and bills the treatment for treatment purposes, while other specialists act as consultants and bills one-time visits for the disease.

As part of each application regarding a disease (injury, other condition), carried out at the expense of compulsory health insurance, medical organizations are required to keep records of directly performed visits as well as directions for laboratory testing in a centralized laboratory.

A visit for an urgent purpose in an outpatient setting - the provision of primary pre-hospital, primary medical, primary specialized health care (including in a clinic, hospital emergency department, at home when calling a medical professional) for sudden acute diseases and conditions (including injuries, poisoning), exacerbation of chronic diseases that are not life-threatening for the patient.

As pre-hospital health care, emergency medical care can be provided by paramedics (paramedics, midwives) who have the right to independently receive patients (determined by order of the chief physician of the medical organization).

Medical assistance to patients who contact a medical organization with signs of an emergency condition is provided immediately. Emergency medical care at home is provided no later than 2 hours after the patient or other person receives a request for emergency care at home.

A mandatory condition for classifying a visit as an emergency visit in an outpatient clinic (unit) or at home is the provision of emergency treatment and diagnostic services using free of charge (at the expense of the medical organization providing medical care) medications, medical products and dressings necessary for the provision of emergency medical care in accordance with the list of vital and essential drugs and medical products necessary for the provision of primary health care in an outpatient setting in an emergency form within the framework of the Territorial Compulsory Medical Insurance Program.

When a patient comes to the emergency department of a hospitalfor emergency and urgent indications(by ambulance, self-referral, etc.) without subsequent hospitalization in this hospital in the case of therapeutic and diagnostic measures (including consultation and examination by a doctor for emergency indications for the purpose of differential diagnosis of a disease or condition), this visit is considered visiting in an emergencyand is presented for payment according to a group of medical service codes 2.82.* “Doctor appointments in the hospital emergency department.” In the case of the use of drugs, medical devices and dressings, the primary medical documentation must contain a record of their use; when performing diagnostic procedures (for example: electrocardiography, radiography, examination of biomaterial, etc.) - the result of the study; when conducting emergency consultations indications – a complete detailed record of the examination and a specialist’s conclusion. In the case of examinations by doctors of different specialties for the purpose of differential diagnosis in the emergency room, each examination is billed as a separate visit for urgent purposes to a doctor of the corresponding specialty. In this case, each of the specialists makes a complete detailed record of the examination and a conclusion in the medical documentation. When a tomographic examination (computed tomography, magnetic resonance imaging) is carried out in a medical organization, when a patient visits the emergency department for emergency and emergency indications, a separate service is billed according to one of the codes:

2.82.26 “Doctor’s appointment in the emergency department of a hospital with a CT scan without contrast”

2.82.27 “Medical appointment in the emergency department of a hospital with a contrast-enhanced CT scan”

2.82.28 “Doctor’s appointment in the emergency department of a hospital with MRI without contrast”

2.82.29 “Medical appointment in the emergency department of a hospital with contrast-enhanced MRI”

according to the profile of the specialist who ordered this study, with justification in the medical documentation for its conduct. The tariff for these codes includes the cost of a medical appointment and the relevant research. The remaining specialists (if necessary) submit their examinations invoiced using the usual codes for visits to the emergency department without conducting a corresponding study (code group 2.82.*, with the exception of the above).

Please note that cases of examination of patients in the emergency department by a specialist doctor for the purpose of selecting them for subsequent planned hospitalization are not invoiced for payment.

Medical organizations keep separate records of visits for preventive purposes (visits to a health center in connection with medical examination of certain population groups, clinical observation, preventive examination, consultations, etc.), emergency medical care and visits for diseases.

Visits made during the day by a patient to the same doctor (paramedical worker) are counted as one visit.

Tariffs for requests from a physiotherapist, physical therapy doctor, reflexology doctor include costs for physiotherapy, reflexology procedures, massage, etc.

Doctor consultations (consultative medical appointments)in medical specialties are used by medical organizations that have advisory (consultative and diagnostic) units and are counted as visits for preventive purposes. A mandatory condition for submitting a consultation case for payment at the rates of code group 2.81.* is the presence of a referral for consultation.

Execution casescomputed and magnetic resonance imaging performed on outpatients(including those insured outside the Volgograd region) are taken into account separately from outpatient visits and are billed for separate services.

Payment for outpatient medical care provided to insured persons at the place of attachment is carried out by insurance medical organizations for a completed visit, treatment or service, the cost of which includes an appointment with a specialist, medical manipulation and examinations prescribed by him. Payment for diagnostic studies (with the exception of computed and magnetic resonance imaging, services of centralized diagnostic laboratories (clinical diagnostic, cytological, prenatal screening, prenatal diagnostics)), carried out by referral from a medical organization to other medical organizations, is made in the form of mutual settlements between them without issuing invoices to medical insurance organizations.

Payment for primary health care provided by local therapists, local pediatricians, and general practitionersto the population not attached to this medical organization, is carried out by insurance medical organizations only when providing medical care in emergency conditions at rates for completed emergency visits. If necessary, repeat visits are made to non-precinct general practitioners and pediatricians and are paid at the rates for a one-time visit for a disease. Visits made to the population not attached to a given medical organization for the purpose of carrying out preventive vaccinations within the framework of the national calendar of preventive vaccinations and the calendar of preventive vaccinations for epidemic indications, for the purpose of dynamic monitoring of the state of development of the child, are paid by insurance medical organizations at the rates for a visit performed for preventive purposes to a doctor. - general practitioner and non-precinct pediatrician. Medical examinations for the population not affiliated with this medical organization are not subject to payment.

Visit to nursing staff

Visits by paramedical personnel (paramedics, midwives) are subject to accounting and are presented for payment in cases of self-administration in medical outpatient clinics, medical and paramedical health centers, first aid posts, including visits regarding procedures (with a recording of the examination in the medical documentation). Midwives of a medical outpatient clinic, a local hospital, a feldsher-midwife station, who independently receive (when assigned to them certain functions of the attending physician, assigned by order of the institution) pregnant women, postpartum women, gynecological patients, children of the first year of life can enter codes of the corresponding services in the account register for payment. Patients visiting the same health care provider during the day are counted as one visit.

Certain features of billing for cases of provision of primary specialized medical care in an outpatient setting

The formation of registers of information and invoices for medical care provided to an insured person during the process of allergen-specific immunotherapy (hereinafter referred to as ASIT) by an allergist-immunologist should be carried out in accordance with the following steps:

1. When making an initial visit to an allergist-immunologist to make a diagnosis and conduct a preliminary examination to identify indications for ASIT (examination by a doctor, laboratory examination and diagnostic procedures - skin tests, prescription of a treatment regimen), when creating registers of information and invoices, the medical service code is used:2.78.7 – Contact an allergist-immunologist for therapeutic purposes.It is permissible to bill at the initial stages of “titration” the dose of allergodrug treatment for therapeutic purposes for several visits to administer the drug of one concentration, until reaching a constant concentration of the drug for long-term ASIT.

2. When directly conducting ASIT according to the scheme prescribed by the allergist-immunologist, when creating registers of information and bills, the medical service code is used:2.88.9 – One-time visit to an allergist-immunologist regarding a disease.

If, during the procedure for introducing the allergen(s) according to the prescribed scheme, complications or exacerbations arose and medical care was required directly from a doctor using medications, then when creating registers of information and invoices, the medical service code is used:2.80.15 – Emergency visit to an allergist-immunologist.

The formation of registers of information and invoices for medical care provided to an insured person in the process of using laser technologies in the treatment of diseases of the organ of vision should be carried out according to service code 2.78.46 “Contacting an ophthalmologist with the use of laser technologies for therapeutic purposes.” A special feature of visiting an ophthalmologist using laser technologies for therapeutic purposes is the presence of two visits, at least one of which must be about laser photocoagulation of the retina, which is necessarily reflected in the medical documentation. This service includes all necessary diagnostic examinations on the day of laser coagulation. The number of courses (stages), frequency of use and volume of intervention are determined individually by an ophthalmologist with mandatory indication in the primary medical documentation.

“TFOMS of the Volgograd Region” asks you to carefully read the procedure for generating accounts and strictly comply with the requirements of the Tariff Agreement. Heads of medical organizations need to take personal control of the implementation of volumetric indicators for outpatient medical care, and bring this information to the attention of doctors and nursing staff who independently receive patients.

Outpatient medical care (lat. ambulatory - mobile, walking; Greek polis - city, clinic- the art of healing, caring for bedridden patients) is carried out outside of hospital conditions.

Currently, about 80% of patients are provided with medical care in outpatient clinics. The outpatient clinic link (the so-called first contact zone) provides for the examination and treatment of patients at the clinic and, if necessary, at home, as well as clinical examination (health monitoring) of the population.

The principle of operation of the outpatient clinic link is territorial-area (the main structural element of the outpatient clinic link of healthcare is the territorial therapeutic area), which implies the permanent assignment of a certain number of residents of the corresponding area to the local therapist and nurse.

The goals and objectives of the outpatient clinic are the following:

Qualified medical care in the clinic and at home.

Clinical examination.

Preventive measures (reducing morbidity, disability and mortality).

Examination of temporary disability.

Sanitary and hygienic education of the population.

Outpatient clinic(lat. ambulatory - mobile, walking) is a medical and preventive institution designed to provide out-of-hospital medical care to the population of a small urban village, a small industrial enterprise or a rural area. In rural areas, outpatient care can be provided by feldsher-midwife stations, which act as the main structural unit of rural healthcare. The local principle of work makes it possible to actively identify patients, provide them with qualified medical care, study morbidity, and carry out preventive and sanitary educational work.

An outpatient clinic differs from a clinic in a certain limitation of the medical care provided and a small number of staff (as well as the number of patients served). As a rule, an outpatient clinic is located in a rural area and provides services to the population with the required minimum number of specialists (no more than five) - a therapist, a surgeon, an obstetrician-gynecologist and a pediatrician.

Medical units provide medical care at large industrial enterprises. They may include a hospital, a clinic, a health center and a dispensary.

Health center- a unit of a medical unit or clinic, organized at industrial enterprises, construction sites, higher and secondary educational institutions, and colleges. Along with providing first aid for injuries, sudden illnesses and poisonings, the health center carries out planned sanitary, hygienic and therapeutic measures to prevent and reduce morbidity. A medical health center is headed by a doctor, a paramedic health center is headed by a paramedic or a nurse.

Women's consultation- a medical and preventive institution that provides treatment and prevention of gynecological diseases, as well as monitoring of pregnant women. A mid-level medical worker - a midwife - assists the doctor during appointments, provides patronage to pregnant women, and teaches them how to care for newborns and personal hygiene. The midwife carries out doctor's orders and carries out health education work.

Ambulance stations provide the population with medical care in emergency situations, working around the clock. The team can be led by a paramedic who independently responds to calls, provides first aid and hospitalizes patients. Specialized medical care, which requires higher qualifications, is provided by a team led by a doctor, and a paramedic assists him in providing assistance and transporting patients. Many ambulance stations have vehicles with modern equipment, which allows them to provide emergency highly qualified and specialized care and carry out resuscitation measures at home and on the way to the hospital.

Additionally, it should be noted that modern domestic healthcare pays great attention to the service of a family doctor (general practitioner) as a promising link in the provision of primary health care. Order of the Ministry of Health of the Russian Federation No. 237 (dated August 26, 1992) provides for the creation of special medical offices (premises) of family medicine, equipped with modern diagnostic equipment, and regulates the staff of such a family medicine office (a family doctor and three paramedical workers, including including laboratory assistant and paramedic). In fact, the general practitioner acts as the legal successor of the local therapist.

Inpatient medical care

If the patient's condition requires systematic monitoring, the use of complex diagnostic and treatment procedures, and specialized medical care, he is sent to a hospital-type hospital.

Hospital (lat. stationarius - standing, motionless) - a structural unit of a medical institution (hospital, medical unit, dispensary), intended for the examination and treatment of patients in a round-the-clock (except for day hospital) stay in this institution under the supervision of medical personnel.

Day hospital- an intermediate link between outpatient and inpatient medical care. This is an inpatient-substituting form of organizing medical care for the population, a structural unit of an outpatient clinic or hospital institution, designed to provide therapeutic, rehabilitation, diagnostic and preventive measures to patients who do not require round-the-clock medical supervision during the daytime.

Dispensary(lat. dispense- distribute) - a special specialized treatment and preventive institution operating according to the dispensary method. The dispensary is intended for active early detection and registration of patients with certain groups of diseases, systematic dynamic monitoring of them, provision of specialized medical care, development of recommendations for improving the health of work and life of these patients, as well as for the study of morbidity and its causes, development and implementation of preventive measures diseases, carrying out sanitary and educational work.

Thus, a dispensary is an independent specialized medical and preventive institution designed to provide medical and preventive care to a certain group of patients. Currently, the domestic healthcare system provides the following types of dispensaries: cardiology, anti-tuberculosis, oncology, dermatovenerological, psychoneurological, narcological, anti-goitrous, endocrinological, medical and physical education.

The goals and objectives of the dispensary are the following::

Active early identification of patients of the relevant profile.

Monitoring of identified patients (patronage).

Specialized medical care.

Rehabilitation of patients.

Prevention of disease.

Study of morbidity and conditions for the development and spread of the disease.

Sanitary educational work.

The importance of patient care cannot be overestimated. Accurate implementation of the doctor’s instructions, carrying out all activities that contribute to the preservation and restoration of the patient’s strength, alleviating his suffering, careful monitoring of the functions of all organs, preventing possible complications, sensitive attitude towards the patient - all this is included in the concept of patient care. And if the doctor treats, then the nurse takes care of you.

Strict compliance with doctor’s orders, strict adherence to dietary, drinking and hygienic regimes, the creation of favorable physical and psychological conditions can restore health even in seemingly hopelessly ill people, and, conversely, poor care, a careless attitude of a nurse to her duties can not only delay recovery of the patient, but also aggravate the severity of his condition.

In everyday life, caring for a patient is understood as providing assistance to him in meeting various needs: food, drink, toilet, movement, physiological functions, etc. Care also implies creating optimal conditions for the patient to stay in a medical institution or at home: peace and quiet, comfortable bed, clean linen, fresh air, etc. This level of care is usually provided by junior medical staff and the patient’s relatives. F. Nightingale wrote: “If, through proper care, all conditions complicating the disease are eliminated, then the disease will take its natural course, and everything collateral, artificial, caused by mistakes, frivolity or ignorance of others will be eliminated.”

In medicine, the concept of “patient care” is interpreted more broadly. Here it stands out as an independent discipline and represents a whole system of measures, including the correct and timely implementation of various medical prescriptions, carrying out diagnostic measures, preparing the patient for certain studies, monitoring the patient’s condition, providing first aid, and maintaining the necessary medical care. documentation.

Patient care influences the effectiveness of treatment and is an integral part of it. The quality of patient care is inextricably linked with the results of treatment of the disease and its prognosis. Thus, with successful management of a patient with myocardial infarction, it is possible to “lose” the patient due to unscrupulous implementation of necessary care measures: for example, the lack of constant monitoring can lead to the patient violating strict bed rest in the first days of myocardial infarction and the development, in particular, of such complications , as fatal cardiac arrhythmias and progression of heart failure. Another example: inadequate control over the cleanliness of bed linen and the condition of the skin under conditions of physical inactivity can lead to the formation of bedsores. That is why patient care is an essential component of treatment, influencing the course of the disease and the patient’s recovery.

There are two main areas of care for patients - general and special care:

· General care - implementation of general care measures regardless of the nature of the disease (general examination, measuring body temperature, changing linen, etc.).

· Special care - implementation of specific care measures depending on the diagnosis of the disease (for example, preparing the patient for cholecystography, catheterization of the bladder).

The document has become invalid or cancelled.

Order of Rosstat dated September 4, 2015 N 412 “On approval of statistical tools for the organization of federal statistical observation in the field of healthcare by the Ministry of Health of the Russian Federation”

Section III. Activities of a medical organization to provide medical care in an outpatient setting

A visit is a contact of a patient with a doctor of a medical organization or unit providing medical care on an outpatient basis for any reason, followed by an entry in the “Medical record of a patient receiving medical care on an outpatient basis” (form N 025/u), including complaints, anamnesis , objective data, diagnoses: main, background, competing and concomitant diseases, injuries, poisonings with their ICD-10 codes, health group, prescribed treatment, examination, as well as the results of examination and follow-up.

The following visits are subject to recording:

Doctors of any specialties who provide outpatient appointments, including consultative appointments (therapists, pediatricians, surgeons, obstetricians-gynecologists, urologists, otolaryngologists, etc., including heads of departments), in medical organizations and outside medical organizations;

Doctors of emergency medical care points (departments) at home;

Doctors at health centers, shop therapists, obstetricians-gynecologists and others who provide outpatient appointments at health centers during hours specially allocated for outpatient appointments;

Doctors providing medical care on specially designated days for appointments on an outpatient basis, when traveling to other medical organizations (district hospitals, district hospitals, outpatient clinics, medical and obstetric centers);

Psychotherapists during group sessions (the number of visits is taken into account according to the number of patients studying in the group);

Visiting a patient or a patient’s relative to refill a prescription (for malignant neoplasms, diabetes mellitus, and other diseases);

Infectious disease doctors conducting door-to-door visits during an outbreak of infectious diseases, examining contacts in the outbreak (family) of an infectious disease;

Consultations of patients on an outpatient basis by doctors of a unit providing medical care in an inpatient setting, for registration of which the “Coupon for a patient receiving medical care on an outpatient basis” (hereinafter referred to as the Coupon) (f. N 025-1/u) is filled out separately for each specialty of the doctor ;

Cases of providing medical care in the emergency departments of medical organizations to patients who are not subject to hospitalization, for the recording of which, in addition to recording in the “Register of admission of patients and refusals of medical care in inpatient conditions” (f. N 001/u), a coupon is filled out;

Consultations by doctors of a unit providing medical care on an outpatient basis to patients undergoing treatment in units providing medical care in an inpatient setting.

Preventive examinations of children in preschool institutions, schools, preventive examinations of the population, including periodic examinations of workers of industrial enterprises, employees of other enterprises (institutions), regardless of whether they are carried out within the walls of a unit providing medical care on an outpatient basis, or directly at enterprises (in institutions);

To the doctors of the draft commissions.

Visits by a patient to the same doctor during the day are counted as one visit.

The following are not counted as doctor visits:

Cases of medical care provided by emergency medical service station (department) personnel;

Examinations in X-ray rooms, laboratories and other auxiliary departments (offices);

Cases of medical care during physical education classes, educational and sports events;

Consultations and examinations conducted by medical commissions (MC) in accordance with Article 48 of the Federal Law of November 21, 2011 N 323-FZ “On the fundamentals of protecting the health of citizens in the Russian Federation”;

Visits to doctors in auxiliary departments (offices), with the exception of cases of “management” of the patient by the doctor of these departments (offices): prescription of treatment with an entry in the primary medical documentation, monitoring and dynamics of the patient’s condition during and after completion of the course of treatment (radiation, physiotherapy and etc.).

Medical visits include:

Visits when the patient is diagnosed with diseases classified in ICD-10 classes I - XX;

Visits to adjust treatment;

Visits to patients under dispensary observation during the period of remission;

Visits to patients in connection with registration of a sanatorium-resort card at MSEC, opening and closing a certificate of incapacity for work, obtaining a certificate of illness of a child, referral for an abortion for medical reasons, regarding pregnancy pathologies, after abortions for medical reasons, as well as for consultations with specialists, if the doctor has established a diagnosis in his specialty.

Preventive visits include conditions classified in class XXI of ICD-10.

If intern doctors conduct appointments under the guidance of a specialist doctor and in his presence, then information about visits is taken into account only in the line corresponding to the position of the specialist doctor.

In cases where interns independently see patients, the information is shown in line 122, regardless of the specialty in which the doctor is undergoing internship.

Visits to doctors in auxiliary departments and offices (radiation therapy, physiotherapy, exercise therapy, endoscopy, functional diagnostics, etc.) are not taken into account in table 2100. The work of auxiliary departments and offices is shown in the corresponding tables of the Form.

Table 2106 shows requests for diseases, injuries, poisoning and some other consequences of external causes (ICD-10 codes: A00 - T98), as well as for preventive and other purposes (ICD-10 codes: Z00 - Z99).

An appeal includes one or more visits to a patient, as a result of which the purpose of the appeal is achieved.

An appeal as a complete case in primary health care and primary specialized health care is one appeal and one or more visits to the patient, as a result of which the purpose of the appeal is achieved. If the purpose of the appeal is not achieved and the Ticket is closed, the case is considered not completed.

Information for table 2400 “Maternity care at home” is taken from the “Logbook of recording obstetric care at home” (registration form N 032/u).

Table 2402. To fill out lines 6 and gr. 3 use “Medical death certificates” (registration form N 106/u-08). Acute cerebrovascular accidents (codes 160 - 164) and myocardial infarction (codes 121 - 122) are included in table 2402 only if they are selected as the underlying cause of death. A medical organization reports only on death certificates issued by this medical organization.

Table 2510. Information about those subject to and examined during medical examinations is included by category: children 0 - 14 years old inclusive (of which: up to 1 year), children 15 - 17 years old inclusive and adults (18 years old and older), examined periodically (order of the Ministry of Health and Social Development of Russia dated April 12, 2011 N 302n, registered with the Ministry of Justice of the Russian Federation on October 21, 2011 N 22111) and other medical examinations.

Table 2510 is filled out only by those medical organizations that organize the examination of the relevant contingents and are responsible for its implementation, and is not filled out by specialized (dermatovenerological, anti-tuberculosis, etc.) organizations that may take part in this work.

The number of individuals subject to inspection and examination includes individuals only once a year, regardless of how many times a year they were subject to inspection and were examined. The planned numbers of those subject to examination by category are approved by order of the head of the medical organization and adjusted at the end of the reporting period. The number of those examined must be equal to the number of those subject to inspection or be less than this number.

6.2. Organization of outpatient care for the urban population.

This type of assistance, as the most widespread and socially significant, occupies a leading place in the medical provision of the population. Outpatient care is most often provided in outpatient clinics and clinics.

Outpatient clinic – an institution that provides care to patients in one or more primary medical specialties.

In the clinic assistance is provided in many specialties.

Both in outpatient clinics and clinics, patients are treated when they contact these institutions, and preventive work is also carried out. In addition, they provide medical care at home.

A polyclinic differs from an outpatient clinic in the volume and level of medical and preventive care; in the latter it is provided by doctors of the main 4 - 5 specialties. Only family doctors (general practitioners) can also provide care in the outpatient clinic.

The importance of clinics and outpatient clinics is determined by their proximity to the population, as well as the possibility of optimal participation in the medical care of the vast majority of the population.

These institutions occupy a leading place in the preventive work of the health care system; their employees identify risk factors among the relevant populations, infectious and socially significant diseases.

The work of outpatient clinics and clinics greatly influences the activities of other healthcare institutions - hospitals, ambulance services. In addition, the level and duration of temporary disability, the frequency of complications of diseases and the consequences of their course, the level of hospitalization, the length of stay of patients in hospitals and, in general, the rational use of beds, as well as, to a large extent, the population’s assessment of the activities of all healthcare systems.

The main tasks of the city clinic:

provision of primary and specialized qualified medical care on an outpatient basis and at home;

carrying out dispensary observation of various contingents;

conducting a medical examination of disability;

organization and implementation of preventive measures, including anti-epidemic ones;

study of population health indicators.

During the period of reform of the healthcare system, the work of the clinic should be aimed at significantly increasing the quality of treatment of the population, a complete comprehensive examination of its socially significant groups, and full-fledged rehabilitation.

All these measures will help reduce the current rather high level of hospitalization and ensure that patients are referred to hospital treatment in cases of extreme need.

Main sections of the clinic:

preventive, including anti-epidemiological measures;

diagnostic and treatment;

organizational and methodological.

To preventive measures include both preventive (primary) and potentially preventive (secondary).

Primary activities:

grafting;

hygienic education of the population;

dispensary observation of healthy people and persons with risk factors;

sanitary and anti-epidemiological measures.

Secondary events:

timely identification of infectious diseases and notification of an infectious patient to the SES;

organization of isolation of patients, monitoring of convalescent contacts;

organization of ongoing disinfection.

Treatment and diagnostic work includes:

early detection of diseases and complete timely examination of patients;

treatment of patients in clinics and at home, including in hospitals at home, using an appropriate set of rehabilitation treatment methods;

provision of emergency medical care in case of a sudden deterioration in the patient’s health;

examination, selection and referral of patients for hospitalization;

selection and examination of patients for sanatorium-resort treatment;

conducting an examination of temporary disability;

selection and referral of patients with signs of permanent disability to MSEC.

Organizational and methodological work includes:

analysis of the health status of the population;

assessment of the activities of the clinic, its departments and personnel;

introduction into practice of new effective methods and methods of prevention, diagnosis and treatment, as well as organizational forms and methods of work;

organization and provision of advanced training for medical staff (direction for postgraduate training and internship in hospitals, holding scientific and practical conferences and seminars).

Structure of the city clinic:

City Polyclinic:

control;

economic part;

registry;

medical and auxiliary departments (physiotherapeutic, exercise therapy, reflexology);

diagnostic departments (X-ray department, laboratory, departments (rooms) of functional diagnostics, endoscopy room, ultrasound room);

first aid room;

treatment and preventive units (departments or rooms of 18-20 specialties);

prevention departments;

other divisions

emergency room;

office of accounting and medical statistics;

day hospital;

state accounting department.

In accordance with the decree of the Ministry of Health of Ukraine No. 127 dated May 21, 1998. instead of accounting rooms and medical statistics, information and analytical departments.

To ensure reception of the population in the clinic and provision of medical care at home doctor positions in cities with a population of more than 25 thousand. in city clinics, which are part of city hospitals (medical units with a hospital), are installed in accordance with the decree of the Ministry of Health of Ukraine No. 33 of February 23, 2000.

Staffing standards for doctors in city clinics

Job titles	Number of positions per 10 thousand. adult (15 years and older) urban population assigned to the clinic.
Local therapist
Cardiologist
Rheumatologist
Surgeon
Orthopedic traumatologist
Urologist
Otolaryngologist
Neuropathologist
Ophthalmologist
Endocrinologist
Infectious disease physician
Allergist, immunologist
Gastroenterologist
Pulmonologist

If the clinic has dermatovenerological, oncological or phthisiatric offices (departments), then a staff of specialist doctors is introduced to receive patients of a particular profile, who are determined according to the staffing standards of the corresponding office (department).

It should be noted that with the improvement of primary health care and the introduction of general practice (family medicine), the ratio of different specialists will change and the provision of doctors of certain specialties to the population will decrease, since family doctors must provide more than 80% of all requests for outpatient care.

The effectiveness of the clinic depends on the proper organization of the work of all its departments and medical staff. This concerns the development of optimal work schedules, regulation of the work of visitors, which is primarily done by senior officials, as well as the reception desk, the pre-medical office and the doctors themselves.

Registry task:

reference and information support;

preliminary and urgent appointments and house calls - telephone and direct patient applications;

regulation of the intensity of the flow of people (referral, if necessary, to the pre-medical office, prevention department, etc.) in order to create an even load of doctors;

registration and storage of medical documentation;

timely selection and delivery of medical documentation to doctors’ offices, in particular outpatient records (if they are stored in the clinic and not among residents).

Medical records in a clinic can be stored according to an alphabetical number system, by area and outpatient medical record numbers, sometimes by street, house and apartment numbers.

Activities for reducing queues at the registration desk, in particular, through the rational staffing of registrars, the distribution of their functions for maintaining records and selecting medical documents.

Reducing queues is facilitated by the availability of complete reference information (determining the location of sites, the names of doctors, their reception hours, the location of offices, the working hours of the clinic, treatment, diagnostic rooms and laboratories, the system of calling a doctor at home, etc.). It is also necessary to organize preliminary telephone appointments and self-appointments with doctors on all days of the week, receiving house calls by telephone, taking into account the work schedules of departments and specific specialists.

The immediate responsibilities of each registrar are determined by the head of the registry. The positions of medical registrars are established at the rate of one per 10 doctors who conduct outpatient visits.

Doctors' working hours The clinic should be:

• fixed at the start of each day of the week;

  dynamic in its duration, which depends on the need to allocate time for servicing house calls and for preventive work, on the seasonal increase in certain diseases.

A shift schedule involves the doctor working at different hours throughout the days of the week. This allows the population to see a doctor in their free time.

A significant part of visits to the clinic occurs at the beginning of the week and the first half of the day, which should be taken into account primarily by doctors when planning the time of repeat and dispensary visits.

In order to reduce the number of unnecessary visits to doctors, clinics are working pre-medical rooms, whose task is to issue referrals for examination, fill out the passport part in the direction to MSEC, sanatorium cards, and measure blood pressure. Experienced nurses are hired to work in pre-hospital rooms.

In a significant number of cases, the population turns first of all to the local doctor, who provides outpatient care on a local-territorial basis. The essence it consists of monitoring the assigned contingents of the territorial site and providing them with qualified medical care.

For maintaining the local principle the following conditions are required:

optimal population size of the site;

staffing the clinic with local doctors;

Availability and adherence to shift work schedules for doctors;

proper organization of the registry work.

Local therapist primarily provides primary health care (PHC), but its functions in its provision are limited compared to those that should be performed by a family doctor who provides patients with multidisciplinary treatment and preventive care and helps them in solving medical and social problems.

The local therapist sees patients in the clinic, visits them at home on calls or on his own initiative, provides dispensary observation for those who require it, and carries out an examination of work ability.

When visiting patients in a clinic, the doctor ascertains the medical history, conducts a physical and instrumental examination, gives recommendations, carries out an examination of the ability to work, and makes appropriate entries in the outpatient’s medical card.

In addition to the timely detection of health problems and provision of first aid to the population of his area, the doctor must, if necessary, provide emergency assistance in case of sudden deterioration in condition, injuries, regardless of the place of residence of the patients.

The responsibilities of the local therapist also include organizing, if necessary, timely hospitalization of patients after a comprehensive examination of them in the clinic.

If a patient needs consultation with the head of the department or other specialist doctors, the therapist must prescribe them and do everything necessary for a timely consultation.

A significant place in the work of a local therapist is occupied by preventive work (medical examinations, clinical examination of certain groups of the population, hygienic education, etc.).

The local therapist has obligations to timely detect infectious diseases and notify the SES about this. He also organizes the isolation of patients and ongoing disinfection at the source of the infectious disease, provides treatment for patients at home, monitors contacts, and conducts (organizes) dispensary observation of those recovering.

Improving the quality of medical care depends significantly on the ability to provide it at home. The volume of this assistance is influenced by the composition of the population by age and gender, morbidity characteristics, the possibility of conducting laboratory and instrumental studies at home, the timeliness of assistance and the quality of treatment, and the territorial location of the sites.

After visiting the patient at home on the day of the call, the doctor can subsequently, if necessary, visit him on his own initiative (active visit). After the patient’s condition improves, they are sent for appropriate procedures or for re-examination at the clinic.

If necessary, the doctor organizes his treatment in a home hospital, involving a local nurse, who carries out the appropriate assignments and monitors the patient’s health.

Carrying out organizational and methodological work, the local therapist studies and analyzes the health status of the population and the indicators of his work.

The staff of district nurses is established at the rate of 1.5 positions for each position of a district therapist (decree of the Ministry of Health of Ukraine No. 33 of February 23, 200).

District nurse assists the doctor during an outpatient appointment - prepares a workplace, checks the availability of the necessary documentation and the receipt of outpatient medical cards from the registry (if they are kept in the clinic and not by residents), if necessary, measures blood pressure, conducts thermometry, explains to patients the procedure for preparation to laboratory instrumental studies. She also fills out, under the supervision of a doctor, medical records (statistical coupons for registering the final diagnosis or outpatient coupons, emergency notifications about infectious diseases, certificates about temporary disability), and issues a referral for diagnostic examinations.

The organization and quality of work of district staff shapes the population’s opinion about medical care in general. The effective operation of this level of outpatient care significantly affects the satisfaction of the need for medical care.

The volume and quality of a doctor’s work is affected by the unevenness of the workload and the treatment of some patients who do not need the help of a doctor at the time of contact.

The unevenness of the load is determined by the seasonal characteristics of the disease of a therapeutic profile, fluctuations in the number of visits on different days of the week and hours throughout the day.

The complex and responsible functions of the local service require planning and coordination of its interaction with various departments of the clinic. This work is provided by Head of the therapeutic department.

This position is introduced if there are 6.5 - 9 positions of general practitioners in the clinic (instead of 0.5 doctor positions). If there are more than 9 general practitioners on staff, the position of the manager is established in addition to these positions, and in this case he is engaged only in his direct management functions.

When introducing the position of head in other departments, the number of positions for specialist doctors of a certain profile may differ. For example, in otolaryngology, ophthalmology and neurology departments, the position of head is introduced when the number of doctors in the relevant specialties is at least 3.0 (instead of 0.5 doctor positions).

Head of therapeutic and other departments of the clinic, manages the activities of all personnel, is responsible for the volume and quality of treatment and preventive work and the diagnostic process.

It provides:

provision of qualified medical and diagnostic care to patients in the clinic and at home;

drawing up optimal work schedules for department staff;

control over the volume, quality of diagnosis and treatment;

participation in the examination of temporary disability and monitoring its quality;

introduction into practice of modern methods of prevention, diagnosis, treatment and work organization;

timely detection and treatment of infectious patients;

planned hospitalization of patients;

control over the completeness and quality of maintaining accounting documents;

drawing up plans and reports;

organization of advanced training for the department's medical staff.

An important structural unit of the clinic is prevention department.

His main tasks:

conducting medical examinations for the purpose of early identification of patients and persons at high risk of disease;

organization, accounting and control of medical examinations;

participation in the development of primary and secondary prevention measures;

promotion of hygienic knowledge.

This department employs predominantly nursing staff on a permanent basis. Its work is supervised by the head of the department - a general practitioner, whose position is established in a clinic that serves 30 thousand or more adults (instead of 0.5 doctor positions).

Doctors of other specialties are invited to work in the prevention department, allocating a certain time in their schedule to conduct medical examinations. If a antenatal clinic is located at the clinic, it provides medical examinations for women. In another case, the structure of the clinic has examination room, for work in which one midwife position is allocated per shift per 30 thousand adult urban population. She must be trained in the specialties of oncology, gynecology and proctology.

The main tasks of a midwife are:

conducting examinations of women with their consent (regardless of age and illness), who were the first to visit the clinic during the year, with the aim of early detection of precancerous diseases and malignant neoplasms;

mandatory collection of smears from the vagina and cervical canal and their sending to a cytology laboratory;

referral of persons with identified pathology to appropriate specialists.

As part of the prevention department, it can act as a structural unit, men's examination room. It employs a paramedic trained in the specialties of oncology, urology and proctology. The purpose of creating this office is the early detection of precancerous diseases and malignant neoplasms.

The activities of the prevention department contribute to the implementation dispensary method, the essence of which is:

active identification of contingents that are subject to clinical examination and their registration;

full comprehensive examination of persons requiring this;

active treatment;

dynamic monitoring of health status;

development and implementation of disease prevention measures and prevention of complications.

Medical examination task:

maintaining the health of the healthy;

early identification of risk factors and initial forms of diseases;

full examination and treatment of patients, improvement of the health of patients at risk;

reduction of morbidity with temporary loss of ability to work and disability;

increase in labor productivity.

The implementation of these tasks is aimed at preserving and strengthening the health of the population.

Contingents of medical examinations are divided into two groups: the first – healthy and persons with risk factors, the second – sick.

The selection of persons for dispensary observation is carried out for both medical and social reasons.

For contingents of the adult population who are subject to dispensary observation for medical reasons, relate:

persons who have risk factors;

patients with certain chronic diseases;

persons who are often and long-term ill.

For social reasons The following are subject to dispensary observation:

persons working in hazardous and hazardous industries;

workers of food, communal and children's institutions;

secondary school teachers;

persons with social risk factors.

Carrying out clinical examination requires a certain sequence.

Stages of clinical examination:

Identification and formation of contingents for dispensary observation.

Accounting of contingents undergoing clinical examination.

Comprehensive examination of persons subject to medical examination.

Dispensary observation and health improvement of the relevant contingents.

Assessing the effectiveness of clinical examination and carrying out organizational and methodological measures, improving its organization and quality.

The effectiveness of clinical observation is influenced by:

application of all necessary methods of prevention, diagnosis and treatment;

coordination of the activities of doctors of relevant specialties;

proper socio-economic living and working conditions.

The selection of contingents for dispensary observation is carried out using:

appeals to health care facilities;

mass and individual medical examinations;

examinations of persons in contact with infectious patients.

In healthcare facilities, targeted, preliminary and periodic medical examinations are carried out.

Targeted medical examinations are carried out to identify certain diseases in the early stages (tuberculosis, neoplasms, etc.).

Preliminary medical examinations are carried out for the purpose of examining certain contingents during recruitment and training.

In accordance with Article 31 of the Fundamentals of Ukrainian Legislation on Health Care (1992), the Cabinet of Ministers of Ukraine, by Resolution No. 532 of August 5, 1994, approved the list of categories of the population that annually undergo mandatory medical examinations at the expense of budgetary funds:

teenagers aged 15-17 years;

vocational school students;

university students;

war veterans; persons who have special services to the Motherland;

labor veterans; persons who have special services to the Motherland;

persons who suffered as a result of the Chernobyl disaster.

Conducting medical examinations of persons who work at food enterprises, enterprises providing sanitary and hygienic services to the population, in health care facilities and other enterprises, as well as drivers of individual vehicles, is carried out on a self-financing basis or at the expense of special funds. For this purpose, the staff of one of the city clinics (city administrative district) that performs this work establishes positions for doctors (therapist, etc.) at the rate of one position per 5,000 people subject to mandatory medical examination.

Medical examinations can be individual or mass. Mass examinations (periodic and targeted) are carried out among organized groups of the population. The forms of their implementation for different population groups may vary in frequency and composition of doctors.

After the medical examination, its results are analyzed, and those examined receive the necessary recommendations. Based on health assessment, they are divided into appropriate health groups:

TO Igroup - healthy – include persons who do not have a history of chronic diseases or dysfunctions of individual organs and systems. During the examination, no deviations from the norm were found.

Co. IIgroup– practically healthy – include persons who have a history of acute or chronic disease that does not affect the functions of vital organs and performance.

TO IIIgroup relate patients with chronic diseases. They are divided into patients.