Reproductive,
perinatal
center and maternity hospital

Plastic and
aesthetic
surgery

Research Institute - scientific-
research
institute

Psychologists
and trainings

Women's
consultation

Wellness
complex
and center

Surgical
center

Preschool educational institution, logo center
and speech pathologist

Any other
organization

Video programs for outpatient card form 025 y

By watching the following video, you can quickly familiarize yourself with the capabilities of the USU program - the Universal Accounting System. If you don't see what's uploaded to YouTube video, be sure to write to us, we will find another way to show the demo video!

Anatoly Wasserman presents the new version 5.0 of the USU program

In addition to opinions about the USU program ordinary users Expert opinions are now presented to your attention. Anatoly Wasserman was born on December 9, 1952. Graduated from the Odessa Technological Institute of Refrigeration Industry, majoring in engineering. After graduation, he worked as a programmer. Then - a system programmer. He first appeared on screen in 1989 in the club “What? Where? When?", then - at the Brain Ring. In the television “Own Game” he won fifteen victories in a row in 2001-2002 and became the best player of the decade in 2004. Five-time champion of Ukraine in the sports version of “Own Game”. Four-time champion of Moscow in the sports version of “My Game”, bronze medalist of the same competition, silver in 2017. Silver medalist of the “Connoisseur Games” - the World Games of Connoisseurs - 2010 in “Your Game”.

Supplement to the program for professional managers - The Bible of the Modern Leader

Addition to the program for professional managers: for business development and increased income. Unique product, developed at the intersection of two sciences: economics and information technology. There are no analogues

USU Mobile App

With the development of technology, life speeds up. You need to be on time everywhere - because the faster you do things, the more you earn. For this reason, it is very important to have a feature-rich mobile application at hand.

Alexander Druz about the Universal Accounting System

In addition to the opinions of ordinary users about the USU program, the opinions of experts are now presented to your attention. Alexander Druz is the first master of the intellectual game "ChGK". He was awarded the Crystal Owl prize six times as the club's best player. Winner of the "Diamond Owl" - a prize for the best player. Champion of the television version of the Brain Ring. In the television program “Own Game” he won “Line Games”, “Super Cup”, won the “III Challenge Cup” with the team, and set an absolute record for performance in one game. Author and presenter mind games and educational programs on various TV channels.

Maxim Potashev on the effectiveness of the USU program

In addition to the opinions of ordinary users about the USU program, the opinions of experts are now presented to your attention. Maxim Potashev - master of the game “What? Where? When?”, four-time winner of the “Crystal Owl” prize, twice world champion, three-time Russian champion, six-time Moscow champion, three-time winner of the Moscow Open Championship in the game “ChGK”. Based on the results of a general audience vote in 2000, he was recognized as the best player in the entire 25 years of the elite club’s existence. 50 thousand viewers of the program voted for the candidacy of Maxim Potashev. He received the “Big Crystal Owl” and the main prize of the anniversary games - the “Diamond Star” of the master of the game. Member of the board and since 2001 - vice-president of the International Association of Clubs. By profession - mathematician, marketer, business coach. Graduated from the Faculty of Management and Applied Mathematics, taught at the Department of General and Applied Economics at MIPT. In August 2010, he was elected president of the All-Russian public organization"Federation of Sports Bridge of Russia." He heads a consulting company that helps various organizations solve problems related to sales, marketing, customer service and business process optimization.

Sergey Karyakin about tactics in business

In addition to the opinions of ordinary users about the USU program, the opinions of experts are now presented to your attention. Sergey Karyakin. At the age of 12 he became the youngest grandmaster in human history. Included in the Guinness Book of Records. Won the Candidates Tournament. Winner of the FIDE World Cup. World champion in rapid chess, world champion in blitz. Honored Master of Sports of Ukraine. Honored Master of Sports of Russia, Grandmaster of Russia. Awarded the Order of Merit, III degree. Member Public Chamber Russian Federation VI composition. Repeated winner of children's and youth world and European championships. Winner and medalist of a number of major tournaments. Champion of the XXXVI World Chess Olympiad as a member of the Ukrainian team, silver medalist of the Olympics as a member of the Russian team. He showed the best result on his board and received the first individual prize (on board 4). Champion of Russia with best result on the 1st board. World champion in the Russian national team. World Cup semi-finalist. Winner of a number of international tournaments.

Name of medical organization Form code according to OKUD __________

Organization code according to OKPO ___________

Medical documentation

Registration form N 025/у

Address ______________________________ Approved by order of the Russian Ministry of Health

MEDICAL CARD

A PATIENT RECEIVING MEDICAL CARE

IN OUTPATIENT CONDITIONS N _____

1. Date of completion medical card: day month Year _____

2. Last name, first name, patronymic _________________________________________________

3. Gender: male - 1, female - 2 4. Date of birth: date ___ month ___ year ___

5. Place of registration: subject of the Russian Federation ________________________

district _____________ city ________________ locality _______________

street _______________ house _________ apartment ________ tel. ________________

6. Location: urban - 1, rural - 2.

7. Compulsory medical insurance policy: series __________ N ______________ 8. SNILS __________________

9. Name of medical insurance organization _________________________

12. Diseases for which it is carried out dispensary observation:

page 2 f. N 025/у

13. Marital status: registered marriage - 1, not married

married - 2, unknown - 3.

14. Education: professional: higher - 1, secondary - 2; overall: average

3, basic - 4, initial - 5; unknown - 6.

15. Employment: working - 1, doing military service and equivalent

service - 2; pensioner - 3, student - 4, not working - 5, others -

16. Disability (primary, repeated, group, date) _____________________

17. Place of work, position ________________________________________________

18. Change of place of work ________________________________________________

19. Change of place of registration _________________________________________________

20. Recording sheet for final (refined) diagnoses:

21. Blood type ____ 22. Rh factor ____ 23. Allergic reactions ________

page 3 f. N 025/у

24. Records of medical specialists:

Date of examination _________ at the reception, at home, at the paramedic-midwife station,

Doctor (specialty) ___________

Patient complaints _________________________________________________________________

___________________________________________________________________________

History of illness, life ________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Objective data ______________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

ICD-10 code ______

ICD-10 code ______

Health group ________ Dispensary observation ______________________

page 4 f. N 025/у

25. Medical observation over time:

page 5 f. N 025/у

page 6 f. N 025/у

page 7 f. N 025/у

26. Stage epicrisis

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Diagnosis of the underlying disease: _______________________ code according to ICD-10 ______

___________________________________________________________________________

Complications: _______________________________________________________________

___________________________________________________________________________

Concomitant diseases ____________________________ ICD-10 code ______

ICD-10 code ______

ICD-10 code ______

External cause for injuries (poisoning) _________________________________

ICD-10 code ______

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Doctor _______________

page 8 f. N 025/у

27. Consultation with the head of the department

Date _________ Temporary disability from _______ (____ days).

Complaints and dynamics of the condition ________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Examination and treatment performed ________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Diagnosis of the underlying disease: _______________________ code according to ICD-10 ______

___________________________________________________________________________

Complications: _______________________________________________________________

___________________________________________________________________________

Concomitant diseases ____________________________ ICD-10 code ______

ICD-10 code ______

ICD-10 code ______

External cause for injuries (poisoning) _________________________________

ICD-10 code ______

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Certificate of incapacity for work _________________________________________________

Head department _______________ Attending physician ______________________________

page 9 f. N 025/у

28. Conclusion of the medical commission

Date ____________

Complaints and dynamics of the condition ________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Examination and treatment performed ________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Diagnosis of the underlying disease: _______________________ code according to ICD-10 ______

___________________________________________________________________________

Complications: _______________________________________________________________

___________________________________________________________________________

Concomitant diseases ____________________________ ICD-10 code ______

ICD-10 code ______

ICD-10 code ______

External cause for injuries (poisoning) _________________________________

ICD-10 code ______

Conclusion of the medical commission: _____________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Chairman _____________ Commission members _________________________________

page 10 f. N 025/у

29. Clinical observation

Date ____________

Complaints and dynamics of the condition ________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Treatment and preventive measures carried out ___________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Diagnosis of the underlying disease: _______________________ code according to ICD-10 ______

___________________________________________________________________________

Complications: _______________________________________________________________

___________________________________________________________________________

Concomitant diseases ____________________________ ICD-10 code ______

ICD-10 code ______

ICD-10 code ______

External cause for injuries (poisoning) _________________________________

ICD-10 code ______

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Doctor _______________

page 11 f. N 025/у

30. Information about hospitalizations

31. Information on surgical interventions performed in outpatient

conditions

32. Sheet for recording radiation doses during x-ray examinations

page 12 f. N 025/у

33. Results of functional research methods:

page 13 f. N 025/у

34. Results of laboratory research methods.

Every person has probably been to a medical facility where one of the important documents serves as a medical record of an outpatient. Neither the doctor nor the patient can do without it.

Why is an outpatient card needed?

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

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

What is a patient's outpatient card?

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

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

Medical documentation can be accounting, reporting and accounting. The outpatient medical record falls into the first category. It describes the diagnoses, the current condition of the patient, and recommendations for treatment.

Introduction of the updated form

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

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

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

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

How is it different from the old form?

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

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

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

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

How is it filled out?

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

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

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

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

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

Filling principles

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

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

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

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

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

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

Extract from outpatient card

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

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

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

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

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

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

The extract can be used to prescribe further medical procedures.

Doctors do not always assess the importance of the rules for maintaining primary medical documentation; they do not pay attention to the basic registration and operational medical, legal documents used in the work, in particular, on whether the registration form 025/у - outpatient card is filled out correctly.

Form N 025/у - the main accounting document of a medical organization providing assistance in outpatient setting adult population

To correctly prepare, record and store an outpatient card, you need to know the requirements and rules for maintaining primary medical records.

Samples of filling and ready-made forms for download.

↯ More articles in the magazine

The main thing in the material of the article

An outpatient medical record must be filled out taking into account the existing rules and requirements for its completion; according to the instructions for maintaining the new form N 025/u, long-term and operational information about the patient must be entered into the medical record.

Accounting form 025/у: maintenance regulations

1. Description of the patient's condition, treatment and diagnostic measures, treatment outcomes and other necessary information.
2. Maintaining the chronology of events that influence clinical and organizational decisions.
3. Reflection in medical documentation of social, physical, physiological and other factors that may affect the patient and the course of the pathological process.
4. Understanding and compliance by the attending physician with the legal aspects of his activities, responsibilities and significance correct design;
5. Recommendations for the patient upon completion of the examination and completion of treatment.

Requirements for obtaining an outpatient card

• reflect the patient’s complaints, medical history, results objective examination, clinical (verified) diagnosis, prescribed diagnostic and therapeutic measures, necessary consultations, as well as all information on monitoring the patient for prehospital stage(prophylactic examinations, results of dispensary observation, visits to an emergency medical service station, etc.);
• identify and record risk factors that may aggravate the severity of the disease and affect its outcome;
• present objective, reasonable information to ensure “protection” of medical personnel from the possibility of a complaint or lawsuit;
• record the date of each entry;
• Each entry must be signed by a doctor (with full name decrypted).
• stipulate any changes, additions, indicating the date of the changes and the signature of the doctor;
• do not allow records that are not related to the provision of medical care to this patient;
• entries in the patient's chart must be consistent, logical and thoughtful;
• promptly refer the patient to a meeting of the medical commission and a medical and social examination;
• devote Special attention records when providing emergency medical care and in complex diagnostic cases;
• justify the prescribed treatment for the preferential category of patients;
• provide for the issuance of prescriptions in 3 copies for preferential categories of patients (one is pasted into the patient’s outpatient card).

What are the requirements for filling out form 025/у?

What is regulated in Form 025/у about the procedure for keeping records in terms of collecting complaints, anamnesis, objective status, examination plan, treatment plan, as well as making records about prescribed medications by international nonproprietary name, in addition to the order?

In addition to the above procedure, the following legal regulations must be followed.

What information should be in an outpatient's medical record?

IN the worksheet provides information about what information needs to be recorded in the card, how to fill them out and when they need to be entered.

Prescribing and prescribing medications

Procedure for appointment and discharge medicines approved by order of the Ministry of Health of Russia dated December 20, 2012 N 1175n.

According to clause 5 of the Procedure, information about the prescribed and discharged medicinal product (name of the medicinal product, single dose, method and frequency of administration or administration, course duration, rationale for prescribing the medicinal product) is indicated in the outpatient patient’s medical record.

Fact of issuing a prescription for a drug legal representative recorded in the patient's medical outpatient record.

Based on clause 3 of the Procedure, the prescription and prescription of medications is carried out by a medical professional using the international nonproprietary name, and in its absence, the generic name.

In the absence of international generic name and the generic name of the medicinal product, the medicinal product is prescribed and prescribed by a medical professional by trade name.

It is allowed to record the names of medicinal products in Latin.

When prescribing narcotic and psychotropic drugs of lists II and III of the List, the dose of which exceeds the highest single dose, the medical worker writes the dose of this drug in words and puts an exclamation point (clause 14 of the Procedure).

Regulations for prescribing and prescribing NS and PV

The procedure for prescribing NS and PV has been changed. A combination of NS with an opioid receptor antagonist has been added to section I of the list of drugs that are subject to subject-quantitative recording. How to prescribe medications now, read the instructions in the magazine "Deputy Chief Physician".

In the article you can also see tables on the forms of forms for NS and PV and extremely permissible quantity NS and PV per prescription.

The method of use of the drug is indicated indicating the dose, frequency, time of administration relative to sleep (morning, at night) and its duration, and for drugs that interact with food - the time of their use relative to meals (before meals, during meals, after food) (clause 17 of the Procedure).

In the cases specified in clause 25 of the Procedure, the prescription of medications is recorded in the patient’s medical documents and certified by the signature of the medical worker and the head of the department (responsible doctor on duty or other authorized person).

If a medicinal product is prescribed by decision of a medical commission, the decision of the medical commission is recorded in the patient’s medical documents (clause 27 of the Procedure).

Thus, when prescribing medications, the patient’s medical record indicates:

1. Name of the medicinal product (international non-proprietary, group or trade; names of medicinal products can be written in Latin).
2. Method of administration (dose, frequency, time of use relative to sleep (morning, at night), duration of use, time of use relative to meals (before meals, during meals, after meals).
3. Rationale for prescribing the drug.
4. The fact that a prescription for a drug was issued to a legal representative (if such a fact exists).
5. The decision of the medical commission to prescribe the drug (in certain cases).
6. Signature of the medical professional who prescribed the drug.
7. Signature of the head of the department, the responsible doctor on duty or another authorized person (in certain cases).
8. Signature of the secretary of the medical commission (in certain cases).

How to provide medical documentation to a patient. New rules

We will explain how to implement the law in practice during an outpatient appointment and in hospital departments.

Instructions

Form N 025/у - the main registration medical document providing medical care on an outpatient basis to the adult population

Differences: outpatient card form 025/у-04 and 025/у

Form No. 025/u has significant differences from its predecessor - form No. 025/-04 “Medical record of an outpatient.” It is more detailed, that is, when filling it out you must indicate large quantity information about the patient.

However, precisely because of its detail, the new form can tell doctors what information about the patient must be included in the primary medical documents.

The procedure for filling out registration form N 025/у

(approved by order of the Ministry of Health of the Russian Federation dated December 15, 2014 N 834n)

1. Accounting form N 025/у (hereinafter referred to as the Card) is the main accounting medical document a medical organization (other organization) providing medical care on an outpatient basis to the adult population (hereinafter referred to as the medical organization).

2. The card is filled out for each patient who seeks medical care in an outpatient setting for the first time. For each patient in a medical organization or its structural unit providing medical care on an outpatient basis, one Card is filled out, regardless of how many doctors provide treatment.

3. Cards are not maintained for patients seeking medical care on an outpatient basis in specialized medical organizations or their structural units in the profiles of oncology, phthisiology, psychiatry, psychiatry-narcology, dermatology, dentistry and orthodontics, who fill out their registration forms.

4. The card is filled out by doctors, medical workers with average vocational education Those conducting independent appointments fill out a logbook for patients receiving medical care on an outpatient basis.

5. Cards in the registry of a medical organization are grouped according to the local principle, Cards of citizens entitled to receive a set social services, are marked with the letter “L” (next to the Card number).

6. The title page of the Card is filled out at the registry of the medical organization when the patient first seeks medical care.

7. The full name of the medical organization is indicated on the title page of the Card in accordance with its constituent documents, OGRN code, the Card number is indicated - the individual Card registration number established by the medical organization.

8. The Card reflects the nature of the course of the disease (injury, poisoning), as well as all diagnostic and therapeutic measures carried out by the attending physician, recorded in their sequence.

9. The card is filled out for each patient visit. The Map is maintained by filling out the relevant sections.

10. Entries are made in Russian, accurately, without abbreviations, all necessary corrections in the Card are made immediately, confirmed by the signature of the doctor filling out the Card. It is allowed to record the names of medicinal products in Latin.

11. When filling out the Card

11.1. In column 1, enter the date of initial filling of the Card. Points 2 - 6 Cards are filled out based on the information contained in the patient’s identification document.

11.2. Clause 7 includes the series and number of the mandatory insurance policy health insurance, clause 8 - insurance number of the individual personal account (SNILS), clause 9 - name of the medical insurance organization.

11.3. Line 10 indicates the benefit category code in accordance with the categories of citizens entitled to receive state social assistance in the form of a set of social services:

• "1" - war invalids;
• "2" - participants in the Great Patriotic War;
• “3” - combat veterans from among the persons specified in subparagraphs 1-4 of paragraph 1 of Article 3 Federal Law dated January 12, 1995 N 5-FZ “On Veterans”;
• "4" - military personnel who passed military service V military units, institutions, military educational institutions that were not part of the active army, in the period from June 22, 1941 to September 3, 1945 for at least six months, military personnel awarded orders or medals of the USSR for service during the specified period;
• “5” - persons awarded the badge “Resident of besieged Leningrad”;
• “6” - persons who worked during the Great Patriotic War at air defense facilities, local air defense facilities, in the construction of defensive structures, naval bases, airfields and other military facilities within the rear boundaries of active fronts, operational zones of active fleets, at front-line sections of railways and highways, as well as crew members of transport fleet ships interned at the beginning of the Great Patriotic War in the ports of other states;
• "7" - members of the families of fallen (deceased) war invalids, participants of the Great Patriotic War and combat veterans, members of the families of those killed in the Great Patriotic War Patriotic War persons from among the personnel of self-defense groups of facility and emergency teams of local air defense, as well as members of the families of deceased workers of hospitals and clinics in the city of Leningrad;
• "8" - disabled people;
• "9" - disabled children.

11.4. Line 11 indicates the patient’s identification document.

11.5. “12” indicates the diseases (injuries) for which dispensary observation of the patient is carried out and their code according to the International Statistical Classification of Diseases and Related Health Problems, tenth revision (hereinafter referred to as ICD-10).

If the patient is under dispensary observation for the same disease by several medical specialists (for example, peptic ulcer from a general practitioner and a surgeon), each such disease is indicated once by the medical specialist who first established the dispensary observation. If the patient is observed for several etiological reasons related diseases from one or more medical specialists, then each of the diseases is noted in paragraph 12 .

11.6. In the “Marital status” section, a record is made of whether the patient is registered married or unmarried, based on the information contained in the patient’s identity document. If there is no information, "unknown" is indicated.

11.7. “Education” is filled out from the patient’s words:

• in the position “professional”, “higher”, “secondary” are indicated;
• in the “general” position, “average”, “basic”, “initial” are indicated.

11.8. 15 - “Employment” is filled out from the words of the patient or relatives:

• The position “carrying out military service or equivalent service” indicates persons undergoing military service or equivalent service;
• The position “pensioner(s)” indicates non-working persons receiving a labor (old age, disability, survivor) or social pension;
• The position “student(s)” indicates students studying in educational organizations;
• The position “not working” indicates able-bodied citizens who do not have a job or income and are registered with the employment service for the purpose of searching suitable job are looking for a job and are ready to start it;
• The position “other” includes persons who are engaged in household work and persons without a fixed place of residence.

11.9. If the patient has a disability, in column 16 indicate “for the first time” or “repeatedly”, the group of disability and the date of its establishment.

11.10. In paragraph 17, according to the patient, the place of work or position is indicated.

11.11. In case of a change in place of work and (or) place of residence, the corresponding changes are indicated in paragraphs 18 and 19.

11.12. 20 - all first or repeatedly established final (refined) diagnoses and the doctor’s full name are indicated.

11.13. In points 21 and 22, the blood type and Rh factor are noted, and in point 23 - allergic reactions that the patient had previously.

11.14. In "24" records of medical specialists are made by filling out the appropriate lines.

11.15. Point 25 is used to record the patient’s condition during observation over time.

11.16. “26” contains a stage-by-stage epicrisis, paragraph 27 - information about the consultation with the head of the department of a medical organization, paragraph 28 - the conclusion of the medical commission.

11.17. Data about the patient for whom dispensary observation is carried out is recorded in section 29.

11.18. 30 contains information about hospitalizations carried out, 31 - information about hospitalizations carried out surgical interventions, in paragraph 32 - information about the received radiation doses during x-ray studies.

11.19. On the pages corresponding to paragraphs 33 and 34, the results of functional and laboratory tests are pasted.

11.20. 35 is used to record the epicrisis. An epicrisis is issued in the event of leaving the service area of ​​a medical organization or in the event of death (posthumous epicrisis).

In case of disposal, the epicrisis is sent to medical organization at the place of medical observation of the patient or given to the patient.

In the event of the patient's death, a post-mortem epicrisis is drawn up, which reflects all past illnesses, injuries, operations, a post-mortem final rubricated (divided into sections) diagnosis is made; the series, number and date of issue of the registration form “Medical Death Certificate” are indicated, and all causes of death recorded in it are also indicated.