Medical form 025 u. Patient's outpatient card: description, form, sample and extract
Outpatient patient card form 025 y is the main document of a patient in an outpatient facility, intended for internal use. The card contains all the important information about the patient necessary to carry out the treatment process in full. The document is drawn up at the reception desk upon the patient’s initial visit. This is where the title page is drawn up.
The outpatient card form is Appendix No. 1 to Order No. 834n of the Ministry of Health, issued in 2014, and is currently used in this form. The document contains 14 pages and includes 35 points for entering data. The medical outpatient card form is also filled out in accordance with the above order. Regulates the procedure for filling out Appendix No. 2.
Medical outpatient card form 025 must contain all passport data about the patient, including marital status. This is part of the basic information that is relevant in the long term (i.e., unchanged for quite a long time or throughout life). These also include: blood type, Rh factor, information on the compulsory medical insurance policy, the availability of benefits and the patient’s existing chronic diseases, allergic reactions, and disability.
Completeness and accuracy of data entry plays an important role in making diagnoses and prescribing treatment. The lack of important information, for example, about the presence of allergic reactions, can lead to serious negative consequences and harm the health and life of the patient.
Medical card form 025u is a registration form of an organization providing outpatient care to the adult population. This form is not filled out by a number of specialized medical organizations that have their own registration forms (see the list in Appendix 2 of Order No. 834n). The data in the form is entered by paramedical workers and doctors conducting treatment.
Outpatient medical record (form 025 y) – repository of operational data
Operational data includes all information that is received in the process of treating a patient, starting from the initial visit to a specialist. The card reflects the results of examinations, established diagnoses, prescribed procedures and necessary medications. All repeat visits and medical observations over time are subject to recording.
The patient's outpatient card may also contain information about the patient's consultation with the head of the department. Columns are provided for recording the conclusions of the medical commission. The medical outpatient record must contain all the patient's test results. Forms with results are filed on a specially designated sheet. The results of laboratory and functional research methods are attached.
Registration form 025 contains an epicrisis - an assessment of the patient’s condition, the diagnosis made, a description of the reasons for the development of the disease, the rationale for the prescribed treatment, and the results obtained. There are generally accepted patterns in writing an epicrisis. This conclusion is written by the attending physician.
You can buy an outpatient card form 025 in our online store. You can purchase from 1 copy. The price is indicated for one unit of goods. When adding the number of card copies, the final cost is calculated automatically. Printing is carried out in the City Blank printing house. The document fully complies with the established form.
Delivery of products is carried out using a courier service. Courier delivery is possible in the Moscow region. You can select the method of payment and receipt of goods when ordering.
Country support:
Operating system: Windows
Family: Universal Accounting System
Purpose: Business automation
Outpatient card form 025 y
Main features of the program:
The program can be translated into any language convenient for you. In addition, you can work with several languages at once
The program allows you to keep an electronic medical history
The program includes academic knowledge with a categorized list of ICD diagnoses
For various ICD diagnoses, a plan for the required examination and treatment has already been drawn up
All test results can also be stored in the program
Setting up filling out templates for research will help optimize the work of all your specialists and eliminate paper documentation
You can attach pictures and any files to the patient’s history
Any company form in MS Word format can be set as a template to fill out
To avoid waiting in line for patients to be seen, you can use pre-registration
The program can even make a call on behalf of your organization and communicate any important information to the patient by voice.
It is possible to use discount cards
Automatic and manual write-off of medications and materials for research is supported. Sales in pharmacy mode
For all services, you can set up costing, and then consumables will be written off automatically
A modern system for working with patients will help employees complete all important tasks on time
You will be able to watch how quickly your client base grows and attract new patients using the modern capabilities of the program
You will find out on which days of the week or days of the month you have the most patients, this will make it easy to manage the workload of each department
The system will show which patients brought you the most profit, and you can easily reward such clients with a personal price list or bonuses
The report will show which patients have not paid for their purchases in full or which suppliers you have not yet fully paid
Every marketing decision you make will be taken into account and analyzed based on the number of new patients and payments
Managers will be able to easily find out which clients you haven’t had for a long time and contact them immediately
Statistics on reasons for leaving will help you avoid patient churn
Your specialists can be easily compared based on various criteria: number of patients, services provided, profit and productivity
You will find out which doctors see patients more often and who may lose your clients
Piece wages of specialists are easily calculated automatically taking into account personal rates
For each doctor or department, you can find out the dynamics of growth in visits and services for any period
A special report will show the most profitable or popular services
You can find out all the statistics on patients, services and specialists for any convenient period of time and evaluate the dynamics using visual reports
You will receive complete statistics on goods sold or spent on services
For each medicine or product, the program will tell you how long its reserves will last, which will allow you to optimize purchases and storage
The purchasing power report will show the financial capabilities of your customers depending on each branch
All financial movements will be under your complete control. You can easily track what you spend the most money on for any period
Analyzing payments according to the values you need will help you decide whether to increase or decrease prices for services and goods
Integration with the latest technologies will allow you to shock your clients and deservedly gain the reputation of the most modern company
Clients will be able to make an appointment on your website with any employee in the selected branch. Current schedule and prices for services
Your patients will be able to find out on the website that tests are ready and download the results in their personal account
The ultra-modern function of communication with a PBX will allow you to see the caller’s data, shock the client by immediately addressing him by name, and not waste a second searching for information
Reliable control will be ensured by integration with cameras: the program will indicate data on the sale, payment received and other important information in the captions of the video stream
Connection with payment terminals so that clients can pay for their services not only at the branch, but also at the nearest terminal. Such payments will be automatically displayed in the program
Payment
terminals
By installing a screen with a visual schedule for employees and offices, you will undoubtedly raise the prestige of your company in the eyes of clients and increase your own control
You can implement customer assessment of the quality of work. The client will receive an SMS in which he will be asked to evaluate the work of the employees. The manager will be able to view the analysis of SMS voting in the program
A special program will save a scheduled copy of all your data in the program without the need to stop working in the system, automatically archive and notify you when it is ready
Reserve
copying
The scheduling system allows you to set up a backup schedule, receive important reports strictly at a certain time, and set any other program actions
You can quickly enter the initial data necessary for the program to work. This is done using convenient manual data entry or import.
The program interface is so easy that even a child can quickly figure it out.
We have completed business automation for many organizations:
Language of the basic version of the program: RUSSIAN
You can also order an international version of the program, into which you can enter information in ANY LANGUAGE of the world. You can even easily translate the interface yourself, since all the names will be placed in a separate text file.
Outpatient card form 025 y is a medical card of a client undergoing outpatient treatment. The patient's outpatient card, form 025, is the main document for recording various procedures provided by the medical treatment center as part of the examination and treatment of its client.
An outpatient medical record, form 025, is drawn up by the medical treatment center upon direct contact from the client and contains a description of his condition, treatment course, set of procedures, step-by-step chronology and results.
Outpatient card form 025 y 04 is the same client’s medical card, the format of which was approved by the Ministry of Health in 2004 and is still used today, where the number “04” has been omitted for brevity. Outpatient card form 025 04 is used in all medical treatment centers providing outpatient care and is marked according to the district affiliation.
You can download the outpatient card form 025 y (025/u-04) on the website of the company “Universal Accounting System” (USU), a developer of specialized software for medical institutions. The outpatient card form 025 y 04, which USU offers to download in its demo version, is filled out in accordance with the instructions developed by the Ministry of Health, which shows step by step how to fill it out.
The rules for filling out an outpatient card, form 025 y (025/y-04), describe which numbered line should contain what information, and also give recommendations on what actions should be taken when maintaining it in the event of any changes in the client’s records or condition.
An outpatient medical record, form 025 y 04, must be kept at the reception desk of the medical treatment center.
Outpatient card form 025, the form of which can be downloaded on the website, when hospitalized, the patient is admitted to the inpatient department and is kept inside his inpatient card. When a client is discharged, the outpatient card form 025/у (025/у-04) is returned back to the medical treatment center at the place of his residence.
The outpatient card, form 025, which is offered for download on the website, requires great attention to filling out the sheet of final diagnoses, where specialists of different profiles indicate the diagnoses they made in the current year.
The medical record of an outpatient patient, form 025, establishes the procedure for the doctor’s actions when he cannot accurately determine the disease - then on the current page of the outpatient record of form 025/u (025/u-04) he notes his presumed diagnosis, and on the sheet of final diagnoses he records only the date of the first appointment, against which the later diagnosis is indicated. Outpatient medical record form 025 y (025/y-04) allows you to correct an inaccurate diagnosis by crossing it out and recording the updated one against the same date of registration of the visit.
The Ministry of Health rarely makes significant changes to medical documentation, so the latest version, called outpatient card form 025, was approved by Kazakhstan in November 2010.
In order for Form 025 to be completed and/or issued by the registry, an outpatient card must be presented.
Outpatient coupon form 025 1 contains information about a patient who wishes to receive medical care on an outpatient basis. The information also includes data on the attending physician’s office hours, the patient’s illness, registration at the dispensary, facts of temporary disability that occurred, etc.
Outpatient coupon form 025 12 y - this is the previous type of coupon, which has already lost its validity; it was replaced by format 025-1/u in 2014.
The outpatient card form 025-1/у is filled out using data from the outpatient card form 025/у (025/у-04) by entering or underlining the desired option from the proposed answers in the coupon itself.
The program can be used by:
Medical Center
and private clinic
Clinic
and outpatient clinic
State
hospital, hospital
and hospital
Laboratory and
diagnostic and treatment
center
Sanatorium and
rehabilitation
center
Dispensary
and preventive
center
Private practitioners
doctors
Eye center
and optics
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 do not see the video uploaded to YouTube, 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 the opinions of ordinary users about the USU program, the opinions of experts 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. A unique product developed at the intersection of two sciences: economics and information technology. There are no analogues
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 of intellectual 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 “Russian Sports Bridge Federation”. 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 of the Public Chamber of the Russian Federation of the 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 the best result on board 1. World champion in the Russian national team. World Cup semi-finalist. Winner of a number of international tournaments.
Form 025/у 04 was put into circulation in 2004. The form was developed by the Ministry of Health. Approving document - Order number 255. An outpatient medical record, form 025/u 04, is used by institutions providing outpatient care (without providing a bed).
Form 025/у 04 is filled out during the patient’s initial visit to an institution or when visiting a home to provide medical services. One copy of the card is created for one patient in one institution. If a patient is seen by several specialists, they use the same document to keep records. Duplication of primary documentation would inevitably introduce confusion into the medical history and complicate treatment.
Outpatient card form 025/у 04 can be used by any medical outpatient organizations, regardless of location or specialization. The form is used by FAPs and health centers. The location of the form is the clinic reception. Here you can fill in the information on the title page.
Medical record form 025/у 04 is a landscape-type card, including a title page and internal pages for entering information. When printing, the form is made in full accordance with the form. Changes to an existing document are not permitted.
Card form 025/у 04 contains important personal information about the patient. The document includes not only basic passport data, but also telephone numbers that allow you to contact the patient, and information about the place of work. The insurance policy number and SNILS must be entered. For people who have any benefits, you must also enter the benefit code. If there is a disability, the corresponding column is filled in. Form 025/у 04 also includes information about a change of address and place of work.
For a medical institution, a medical card (form 025/у 04) is the main document of a citizen receiving outpatient services. The form contains up-to-date information about the patient’s main diagnosed diseases. Information about the presence of existing diseases that are subject to dispensary observation is entered in the appropriate columns. This is an important resource for the attending physician.
Information about such patient parameters as blood type, Rh factor and drug intolerance is also important. These data play a major role in the provision of certain types of emergency care and surgical interventions.
The map contains loose leaves that describe the dynamics of the disease. All visits or services provided at home are recorded. The form also records cases of issuance of certificates of incapacity for work. During treatment, the patient may require hospitalization in an inpatient clinic. In this case, form 025/у 04 is transferred to the hospital for the duration of treatment and is added to the main medical record of the patient in the hospital.
Buy an outpatient medical card form 025/у 04
You can buy a patient’s medical card form 025 from 04 in Moscow at the City Blank printing house. We can produce outpatient card form 025/у 04 in a single copy or print a batch of the required size. A certain number of forms may be in stock. Check availability with managers.
You can pick up your medical card in person when you visit our offices. You can order courier delivery to your door. We also cooperate with the largest shipping companies, and can send purchases to any region of Russia. Postal delivery to the desired location is possible.
Name of medical organization Form code according to OKUD __________
Organization code according to OKPO ___________
Medical documentation
Registration form N 025/у
Address ______________________________ Approved by order of the Russian Ministry of Health
MEDICAL CARD
A PATIENT RECEIVING MEDICAL CARE
IN OUTPATIENT CONDITIONS N _____
1. Date of filling out the medical record: date ___ month _____ year _____
2. Last name, first name, patronymic _________________________________________________
3. Gender: male - 1, female - 2 4. Date of birth: date ___ month ___ year ___
5. Place of registration: subject of the Russian Federation ________________________
district _____________ city ________________ locality _______________
street _______________ house _________ apartment ________ tel. ________________
6. Location: urban - 1, rural - 2.
7. Compulsory medical insurance policy: series __________ N ______________ 8. SNILS __________________
9. Name of medical insurance organization _________________________
12. Diseases for which dispensary observation is carried out:
|
Start date of clinical observation |
Date of termination of dispensary observation |
ICD-10 code | ||
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:
|
Date (day, month, year) |
Final (refined) diagnoses |
Installed for the first time or again (+/-) | |
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 ______________________
|
Discount recipes |
|
|
Informed voluntary consent to medical intervention, refusal of medical intervention |
|
page 4 f. N 025/у
25. Medical observation over time:
|
Observation data over time |
|
|
Appointments (research, consultations) |
Medicines, physiotherapy |
|
Certificate of incapacity for work, certificate |
Discount recipes |
|
Observation data over time |
|
|
Appointments (research, consultations) |
Medicines, physiotherapy |
|
Certificate of incapacity for work, certificate |
Discount recipes |
page 5 f. N 025/у
|
Observation data over time |
|
|
Appointments (research, consultations) |
Medicines, physiotherapy |
|
Certificate of incapacity for work, certificate |
Discount recipes |
|
Observation data over time |
|
|
Appointments (research, consultations) |
Medicines, physiotherapy |
|
Certificate of incapacity for work, certificate |
Discount recipes |
page 6 f. N 025/у
|
Observation data over time |
|
|
Appointments (research, consultations) |
Medicines, physiotherapy |
|
Certificate of incapacity for work, certificate |
Discount recipes |
|
Observation data over time |
|
|
Appointments (research, consultations) |
Medicines, physiotherapy |
|
Certificate of incapacity for work, certificate |
Discount recipes |
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 institution, where one of the most important documents is the medical record of an outpatient. Neither the doctor nor the patient can do without it.
Why is an outpatient card needed?
How correctly this document is filled out may determine the fate of the patient in the framework of a possible criminal or civil case being investigated in relation to him.
An extract from the outpatient card is required:
⦁ when carrying out forensic medical examinations;
⦁ to make payments for the provision of medical care under compulsory medical insurance contracts;
⦁ to conduct medical and economic examinations to monitor the quality of medical services provided.
What is a patient's outpatient card?
In Federal Law No. 323, approved in November 2011, regulating the health protection of our compatriots, there is no such thing as medical documentation.
The medical encyclopedia includes a system of documents that have a prescribed form, the purpose of which is to register information about measures for prevention, treatment, diagnosis and sanitary hygiene.
Medical documentation can be accounting, reporting and accounting. The outpatient medical record falls into the first category. It describes the diagnoses, the current condition of the patient, and recommendations for treatment.
Introduction of the updated form
Order of the Russian Ministry of Health No. 834 of December 2014 approved updated unified forms of documentation used by outpatient medical institutions. It also states how they are filled out.
This is a significant step towards the creation of an electronic medical record, since the introduction of uniform standards in the execution of records ensures mutual continuity among medical institutions.
In particular, form No. 025/u - “Medical record of an outpatient patient” has been developed, and it is described in detail how it should be filled out. In addition, a sample patient coupon with the appropriate filling procedure has been approved.
The above-mentioned order gave this card the status of the main registration medical document of an institution providing medical care for the adult population using outpatient conditions.
How is it different from the old form?
In the new accounting form, the information content has been significantly increased, and the positions to be filled out have been specified in more detail. In the previous version, the doctor could make notes at his own discretion; now they are unified.
The following information was required to be entered:
⦁ about consultations with narrow medical specialists and the head of the department;
⦁ about the result of the meeting of the All-Conference Committee;
⦁ about taking x-rays;
⦁ on making a diagnosis according to the 10th International Qualification of Diseases.
For each specialized medical institution or their specialized structural area in dentistry, oncology, dermatology, psychology, orthodontics, psychiatry and narcology, its own outpatient card has been developed. Form No. 043-1/u, for example, is filled out for orthodontic patients, No. 030/u is intended for a control card for dispensary observation.
Form No. 030-1/u-02 is issued for persons suffering from psychiatric diseases and drug addiction. It was approved in Order of the Ministry of Health of the Russian Federation of 2002 No. 420.
How is it filled out?
During a person’s very first visit to the clinic, the receptionist fills out the data on the title page. But a patient’s outpatient card can only be filled out by doctors.
If the patient belongs to the category of federal beneficiaries, an “L” is indicated next to the card number. The doctor must make an appropriate record of each patient’s visit to the clinic.
The outpatient card reflects:
⦁ how the disease progresses;
⦁ what diagnostic and therapeutic measures are consistently carried out by the attending physician.
The entry is made carefully, in Russian, in the appropriate section without any abbreviations. If it is necessary to correct something, this is done immediately after the mistake is made and must be certified by a doctor’s signature.
It is acceptable to use Latin to write the names of medications.
The health worker fills out the first sheet in the registry according to the data from the patient’s identification documents. Workplace and position graphs are recorded according to the patient’s words. The form contains recommendations for completing each section.
Filling principles
When filling out an outpatient card, you should remember some basic principles.
It should describe in chronological order:
⦁ in what condition the patient came to see the doctor;
⦁ what diagnostic and therapeutic procedures were performed;
⦁ treatment results;
⦁ circumstances of a physical, social and other nature that influence the patient during pathological changes in his well-being;
⦁ the nature of the recommendations given to the patient at the end of the examination and treatment process.
The doctor must comply with all legal aspects when filling out the form.
The outpatient card consists of forms on which long-term and operational information is recorded.
Long-term information contained on front-adhesive sheets includes:
⦁ information copied from an identity document;
⦁ blood group with Rh factor;
⦁ information about previous infectious diseases and allergic reactions;
⦁ final diagnoses;
⦁ results of preventive examinations;
⦁ list of prescribed narcotic drugs.
Operational information is recorded on inserts where the results of the initial visit and secondary visits to the local therapist, specialized doctors, and consultations with the head of the department are recorded.
Extract from outpatient card
An extract is a medical certificate of health in form 027/y, which belongs to the second group of medical records documentation. It contains information about illnesses suffered during outpatient treatment.
Its purpose, like all the documentation of this group, is to quickly exchange data on the health of patients, which helps to connect the individual stages of sanitary-preventive and therapeutic measures.
The extract can be provided by the patient to the employer to inform about the completion of outpatient treatment. It is not subject to payment, but is submitted together with the sick leave certificate, if the latter is issued for more than a month.
This document allows you to be exempt from classes in educational institutions.
The extract contains information about the patient, indicating the medical policy number, listing his complaints, symptoms of the disease, the results of medical examinations and examinations, as well as the primary diagnosis.
All information must fully correspond to that contained in the outpatient card.
The extract can be used to prescribe further medical procedures.
