Medical form 025 c.u. Outpatient card of the patient: description, form, sample and extract
The outpatient card of the patient form 025 y is the main document of the patient of an outpatient facility, intended for internal use. The card contains all the important information about the patient, necessary for the implementation of the treatment process in full. The document is issued in the registry at the initial treatment of the patient. Here is the title page.
The outpatient card form is Appendix No. 1 to the order of the Ministry of Health No. 834n, issued in 2014, and is currently used in this form. The document contains 14 pages and includes 35 data points. The form of a medical outpatient card is also filled in in accordance with the above order. Regulates the procedure for filling out Appendix No. 2.
Outpatient medical card form 025 y must contain all the patient's passport data, including marital status. It is a piece of 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 of the compulsory medical insurance policy, the availability of benefits and the patient's chronic diseases, allergic reactions, and disability.
The 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 025y is a record 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.
Medical record of an outpatient (form 025 y) - a repository of operational data
Operational data includes all the information that comes in the process of treating a patient, starting with the initial visit to a specialist. The card reflects the results of examinations, established diagnoses, prescribed procedures and necessary medications. All repeated visits, medical observations in dynamics are subject to fixation.
The outpatient card of the patient may also contain data on the patient's consultation with the head of the department. Columns are allocated for fixing the conclusions of the medical commission. The medical outpatient record must contain all the results of the patient's tests. Forms with the results are filed on a specially designated sheet. Attached are the results of laboratory and functional research methods.
Accounting form 025 y contains an epicrisis - an assessment of the patient's condition, a diagnosis, a description of the causes of the development of the disease, the argumentation of the prescribed treatment, and the results obtained. In writing an epicrisis, there are generally accepted schemes. This conclusion is written by the attending physician.
You can buy an outpatient card form 025 y in our online store. Purchase from 1 copy is possible. The price is for one item. When adding the number of copies of the card, the final cost is calculated automatically. Printing is carried out in the City Blank printing house. The document is fully consistent with the established form.
Delivery of products is carried out using a courier service. Courier delivery is possible on the territory of the Moscow region. You can choose 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
The 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 diagnoses according to the ICD, a plan for the required examination and treatment has already been drawn up
All test results can also be stored in the program
Customizing the filling of research templates will help optimize the work of all your specialists and get rid of paper documentation
Pictures and any files can be attached to the patient's history
Any letterhead in MS Word format can be set as a template for filling
To prevent patients from waiting in line for an appointment, you can use a pre-registration
The program will even be able to call on behalf of your organization and voice inform the patient of any important information
It is possible to use discount cards
Automatic and manual write-off of medicines and materials for research is supported. Pharmacy sales
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 your client base grow rapidly and attract new patients with the help of modern program features
You will find out on which days of the week or day of the month you have the most patients, this will allow you to easily manage the workload of each department
The system will show which of the patients brought you the most profit, and you can easily encourage such clients with a personal price list or bonuses
The report will show which of the patients did not fully pay for their purchases or with which of the suppliers you have not yet fully paid
Each of your marketing decisions will be taken into account and analyzed by the number of new patients and payments
Managers can easily find out which of your clients have not appeared for a long time and immediately contact them
Reasons for leaving statistics will help you avoid patient churn
Your specialists can be easily compared according to various criteria: number of patients, services rendered, profit and productivity
You will find out which doctors are more likely to return patients, and who can lose your clients
Piecework wages for specialists are easily calculated automatically, taking into account personal rates
For each doctor or department, you can find out the growth dynamics of 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 full statistics on the goods sold or spent on services
For each medicine or product, the program will tell you how long its stocks will last, which will optimize purchases and storage
The purchasing power report will show the financial capacity 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
Analysis of 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 customers and earn a well-deserved reputation as the most modern company.
Clients will be able to sign up on your site to any employee in the selected branch. Current schedule and prices for services
Your patients will be able to find out on the website about the readiness of tests and download the results in their personal account
The ultra-modern function of communication with the PBX will allow you to see the details of the caller, shock the client by immediately addressing him by name, without wasting a second searching for information
Reliable control will be ensured by integration with cameras: the program will indicate sales data, payment received and other important information in the captions of the video stream
Communication with payment terminals so that customers can pay for their services not only at the branch, but also at the nearest terminal. Such payments will automatically be 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 customers and increase your own control
You can implement customer performance appraisals. The client will receive an SMS in which he will be asked to evaluate the work of employees. The manager will be able to view the analysis of SMS voting in the program
A special program will save a copy of all your data in the program on a schedule without the need to stop working in the system, automatically archive and notify you of readiness
Reserve
copying
The scheduling system allows you to set up a backup schedule, receive important reports strictly at a specific time, and set any other program actions
You can quickly enter the initial data necessary for the program to work. For this, convenient manual entry or data import is used.
The interface of the program 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 the international version of the program, in which you can enter information in ANY LANGUAGE of the world. Even the interface can be easily translated by 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 outpatient card of the patient form 025 y is the main document for recording the various procedures provided by the medical treatment center as part of the examination and treatment of its client.
The outpatient medical record form 025 y is issued by the medical treatment center at the direct request of the client and contains a description of his condition, treatment course, a set of procedures, a step-by-step chronology and results.
Outpatient card form 025 y 04 is the same client medical card, the format of which was approved by the Ministry of Health in 2004 and is still used today, where the number “04” was omitted for brevity. The outpatient card form 025 y 04 is used in all medical treatment centers that conduct outpatient appointments and is marked according to the district affiliation.
You can download the outpatient card form 025 y (025 / y-04) on the website - the website of the Universal Accounting System (USU), a developer of specialized software for medical institutions. The outpatient card form 025 y 04, which the USU offers in its demo version, is filled out according to 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 case of any changes in the records or the client's condition.
The medical card of an outpatient, form 025 at 04, must be kept at the registry of the medical treatment center.
An outpatient card form 025 y can be downloaded from the website, when a patient is hospitalized, he enters the inpatient department and is contained inside his inpatient card. When the client is discharged, the outpatient card form 025 / y (025 / y-04) is returned back to the medical center at his place of residence.
The outpatient card form 025, which is offered for download on the website, requires great attention to filling out the final diagnosis sheet, where specialists of different profiles indicate the diagnoses they have made in the current year.
The outpatient medical record form 025 establishes the procedure for the doctor to act when he cannot accurately determine the disease - then on the current page of the outpatient card form 025 / y (025 / y-04) he notes the diagnosis he suspects, and on the sheet of final diagnoses he registers only the date of the first appointment, against which the diagnosis established later is indicated. The medical card of an outpatient form 025 y (025 / y-04) allows you to correct an inaccurate diagnosis by crossing it out and recording an updated visit against the same date of registration.
The Ministry of Health rarely makes significant changes to medical records, so the latest version called outpatient card form 025 was approved by Kazakhstan in November 2010.
In order for Form 025 to be issued and / or issued by the registry, an outpatient coupon must be presented.
Outpatient coupon form 025 1 y contains information about a patient who wants to receive medical care on an outpatient basis. The information also includes data on the attending physician's appointment hours, on the patient's malaise, dispensary registration, on the facts of temporary disability that took place, etc.
The outpatient coupon form 025 12 y is the previous type of coupon, which has already become invalid; in 2014, format 025-1 / y was approved to replace it.
The outpatient coupon form 025-1 / y is filled out using the data from the outpatient card form 025 / y (025 / y-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
Polyclinic
and dispensary
State
hospital, hospital
and hospital
Laboratory and
medical diagnostic
center
Sanatorium and
rehabilitation
center
dispensary
and preventive
center
Private practitioners
doctors
eye center
and optics
reproductive,
perinatal
center and 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, logopoint
and defectologist
Any other
organization
Video program for outpatient card form 025 y
After watching the following video, you can quickly get acquainted with the capabilities of the USU program - the Universal Accounting System. If you can't see the video uploaded to YouTube, be sure to email us, we'll find another way to show the demo!
Anatoly Wasserman presents a 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 the Refrigeration Industry as an engineer. After graduation, he worked as a programmer. Then - the system programmer. For the first time he appeared on the screen in 1989 in the club “What? Where? When? ”, Then - on 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 "Own Game", bronze medalist of the same competition, silver 2017. Silver medalist of the "Connoisseurs" - the World Games of Connoisseurs - 2010 in "Own Game".
Supplement to the Program for Professional Managers - Modern Manager's Bible
Addition to the program for professional managers: to develop business and increase income. A unique product developed at the intersection of two sciences: economics and information technology. There are no analogues
As technology advances, life speeds up. Everywhere you need to be in time - because the faster you do things, the more you earn. For this reason, it is very important to have a multifunctional 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 - the first master of the intellectual game "ChGK". Six times he was awarded the "Crystal Owl" prize as the best player of the club. Winner of the "Diamond Owl" - a prize for the best player. Champion of the television version of "Brain Ring". In the television program “Own Game” he won the “Line Games”, “Super Bowl”, won the “III Challenge Cup” with the team, set an absolute performance record 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, two-time world champion, three-time champion of Russia, six-time champion of Moscow, three-time winner of the Moscow Open Championship in the game “ChGK”. According to the results of the general audience vote in 2000, he was recognized as the best player in all 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 - a mathematician, marketer, business coach. He graduated from the Faculty of Management and Applied Mathematics, taught at the Department of General and Applied Economics at the Moscow Institute of Physics and Technology. 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. Sergei Karyakin. At the age of 12, he became the youngest grandmaster in the history of mankind. Listed in the Guinness Book of Records. Won the Candidates Tournament. FIDE World Cup Winner. World Rapid Chess Champion, World Blitz Champion. Honored Master of Sports of Ukraine. Honored Master of Sports of Russia, Grandmaster of Russia. He was awarded the Order of Merit, III degree. Member of the Civic Chamber of the Russian Federation of the VI composition. Repeated winner of children's and youth championships of the world and Europe. Winner and prize-winner of a number of major tournaments. Champion of the XXXVI World Chess Olympiad as a member of the Ukrainian team, silver medalist of the Olympiad as a member of the Russian team. He showed the best result on his board and got the first individual prize (on the 4th board). Champion of Russia with the best result on the 1st board. World champion in the Russian team. Semi-finalist of the World Cup. Winner of several international tournaments.
Form 025/y 04 was put into circulation in 2004. The form was developed by the Ministry of Health. Approving document - Order number 255. The outpatient medical record form 025 / y 04 is used by institutions providing outpatient care (without providing a bed).
Form 025 / y 04 is filled out during the initial visit to the institution by the patient or when leaving the house to provide medical services. One copy of the card is created for one patient in one institution. If the patient is observed by several specialists, then they use the same document to keep records. Duplication of primary documentation would inevitably confuse the case history and complicate treatment.
Outpatient card form 025 / y 04 can be used by any medical outpatient organization, regardless of location or specialization. The form is used by FAPs and health centers. The location of the form is the clinic registry. This is where you fill in the information on the title page.
Medical card form 025 / y 04 is a landscape-type card that includes a title page and inner pages for entering information. When printing, the form is made in full accordance with the form. Changes to an existing document are not allowed.
Card form 025/y 04 contains important personal information about the patient. The document includes not only basic passport data, but also phone numbers that allow you to contact the patient, information about the place of work. Be sure to enter the number of the insurance policy and SNILS. For people who have any benefits, you must also enter the benefit code. If there is a disability, the appropriate column is filled in. Information about the change of address and place of work is also entered into the form 025 / y 04.
For a medical institution, a medical card (form 025 / y 04) is the main document of a citizen receiving outpatient services. The form contains up-to-date information about the main diagnosed diseases of the patient. Information about the presence of already existing diseases subject to dispensary observation is entered in the appropriate columns. This is an important source for the attending physician.
Information about such parameters of the patient 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, surgical interventions.
The map contains loose sheets that describe the dynamics of the course of diseases. All visits or home services are recorded. The form also records cases of issuing disability certificates. During treatment, the patient may require hospitalization in a hospital at the clinic. In this case, form 025 / y 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 a medical card for an outpatient form 025 / y 04
You can buy a medical card of a patient form 025 y 04 in Moscow at the City Blank printing house. We can make a single copy of the outpatient card form 025 / y 04 or print a batch of the desired size. A certain number of molds may be in stock. Check availability with managers.
You can pick up a medical card in person when visiting our offices. It is possible to order courier delivery to the door. We also cooperate with the largest carrier companies, and we can send the purchase 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
Accounting form N 025 / y
Address ______________________________ Approved by order of the Ministry of Health of Russia
MEDICAL CARD
PATIENT RECEIVING MEDICAL CARE
IN OUTPATIENT CONDITIONS N _____
1. Date of completion of the medical record: day ___ month _____ year _____
2. Surname, name, patronymic _________________________________________________
3. Gender: male. - 1, female - 2 4. Date of birth: day ___ month ___ year ___
5. Place of registration: subject of the Russian Federation ________________________
district _____________ city ________________ settlement _______________
street _______________ building _________ apartment _______ tel. ________________
6. Terrain: urban - 1, rural - 2.
7. MHI policy: series __________ N ______________ 8. SNILS __________________
9. Name of the insurance medical organization _________________________
12. Diseases for which dispensary observation is carried out:
|
Start date of dispensary observation |
Date of termination of dispensary observation |
ICD-10 code | ||
page 2 f. N 025/y
13. Marital status: is in a registered marriage - 1, not a member
married - 2, unknown - 3.
14. Education: professional: higher - 1, secondary - 2; general: average
3, basic - 4, initial - 5; unknown - 6.
15. Employment: works - 1, performs military service and equivalent to it
service - 2; pensioner (ka) - 3, student (ka) - 4, not working - 5, others -
16. Disability (primary, repeated, group, date) _____________________
17. Place of work, position _______________________________________________
18. Change of job ________________________________________________
19. Change of place of registration ___________________________________________
20. Record sheet of final (specified) diagnoses:
|
Date (day, month, year) |
Final (specified) diagnoses |
Installed for the first time or re-installed (+/-) | |
21. Blood type ____ 22. Rh factor ____ 23. Allergic reactions _______
page 3 f. N 025/y
24. Records of medical specialists:
Date of examination _________ at the reception, at home, at the feldsher-obstetric station,
Doctor (specialty) ___________
Patient's complaints _______________________________________________________________
___________________________________________________________________________
History of disease, life ________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Objective data ______________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
ICD-10 code ______
ICD-10 code ______
Health group ________ Dispensary observation _________
|
Preferential prescriptions |
|
|
Informed voluntary consent to medical intervention, refusal of medical intervention |
|
page 4 f. N 025/y
25. Medical supervision in dynamics:
|
Observation data in dynamics |
|
|
Appointments (research, consultations) |
Medications, physiotherapy |
|
Disability certificate, certificate |
Preferential prescriptions |
|
Observation data in dynamics |
|
|
Appointments (research, consultations) |
Medications, physiotherapy |
|
Disability certificate, certificate |
Preferential prescriptions |
page 5 f. N 025/y
|
Observation data in dynamics |
|
|
Appointments (research, consultations) |
Medications, physiotherapy |
|
Disability certificate, certificate |
Preferential prescriptions |
|
Observation data in dynamics |
|
|
Appointments (research, consultations) |
Medications, physiotherapy |
|
Disability certificate, certificate |
Preferential prescriptions |
page 6 f. N 025/y
|
Observation data in dynamics |
|
|
Appointments (research, consultations) |
Medications, physiotherapy |
|
Disability certificate, certificate |
Preferential prescriptions |
|
Observation data in dynamics |
|
|
Appointments (research, consultations) |
Medications, physiotherapy |
|
Disability certificate, certificate |
Preferential prescriptions |
page 7 f. N 025/y
26. Stage epicrisis
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Diagnosis of the underlying disease: _______________________ ICD-10 code ______
___________________________________________________________________________
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/y
27. Consultation of the head of the department
Date _________ Temporary disability since _______ (____ days).
Complaints and dynamics of the state _______________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Conducted examination and treatment ____________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Diagnosis of the underlying disease: _______________________ ICD-10 code ______
___________________________________________________________________________
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/y
28. Conclusion of the medical commission
The date ____________
Complaints and dynamics of the state _______________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Conducted examination and treatment ____________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Diagnosis of the underlying disease: _______________________ ICD-10 code ______
___________________________________________________________________________
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/y
29. Dispensary observation
The date ____________
Complaints and dynamics of the state _______________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Conducted therapeutic and preventive measures _____________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Diagnosis of the underlying disease: _______________________ ICD-10 code ______
___________________________________________________________________________
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/y
30. Information about hospitalizations
31. Information about the performed surgical interventions in outpatient
conditions
32. Sheet of accounting for radiation doses during X-ray studies
page 12 f. N 025/y
33. Results of functional research methods:
page 13 f. N 025/y
34. Results of laboratory research methods.
Each person probably had to visit medical institutions, 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 do I need an outpatient card?
The fate of the patient within the framework of a possibly investigated criminal or civil case may depend on how correctly this document is filled out.
An extract from the outpatient card is required:
⦁ in the implementation of forensic examinations;
⦁ to make payments for the provision of medical care under compulsory medical insurance contracts;
⦁ to conduct medical and economic examinations to control the quality of medical services performed.
What is an outpatient patient card?
In the Federal Law No. 323, approved in November 2011, which regulates the protection of the health of our compatriots, there is no such thing as medical documentation.
The Medical Encyclopedia refers to it a system of documents that have an established 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 belongs to the first category. It describes the diagnoses, the current condition of the patient, 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 in circulation in outpatient medical institutions. It also states how they are filled.
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 / y - "Medical record of an outpatient" has been developed, and it is described in detail how it should be filled out. In addition, a sample of the patient's coupon with the appropriate filling procedure has been approved.
By the above order, this card was given the status of the main accounting medical document of an institution providing medical care for the adult population using outpatient conditions.
What is the difference from the old form?
In the new accounting form, the information content is significantly increased, the positions filled in are specified in more detail. In the previous version, the doctor could make notes at his own discretion, now they are unified.
Be sure to enter the following information:
⦁ about consultations of narrow medical specialists and the head of the department;
⦁ on the outcome of the CWC meeting;
⦁ about taking x-rays;
⦁ on the diagnosis of the 10th International Qualification of Diseases.
For each specialized medical institution or their profile structural direction in dentistry, oncology, dermatology, psychology, orthodontics, psychiatry and narcology, an outpatient card has been developed. Form No. 043-1 / y, for example, is filled out for orthodontic patients, No. 030 / y is intended for a control card for dispensary observation.
Form No. 030-1 / y-02 is issued to persons suffering from psychiatric diseases and drug addiction. It was approved in the Order of the Ministry of Health of the Russian Federation of 2002 No. 420.
How is it filled?
During the very first visit of a person to the clinic, the registry fills in the data on the title page. But the outpatient card of the patient can only be filled out by doctors.
If the patient belongs to the category of federal beneficiaries, "L" is affixed next to the card number. The doctor must make an appropriate record of each visit to the clinic by the patient.
Outpatient card reflects:
⦁ how the disease proceeds;
⦁ what diagnostic and therapeutic measures are consistently carried out by the attending physician.
The recording is done neatly, 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 medical signature.
It is permissible to use Latin to write the names of medicines.
The health worker fills out the first sheet in the registry according to the data from the patient's identity documents. The graphs of the workplace and positions are recorded according to the patient. The form contains instructions for completing each section.
Filling principles
When filling out an outpatient card, there are some basic principles to keep in mind.
It should describe in chronological order:
⦁ in what condition did the patient come to see the doctor;
⦁ what diagnostic and treatment procedures were performed;
⦁ results of treatment;
⦁ circumstances of a physical, social and other nature that affect the patient during pathological changes in his state of health;
⦁ the nature of the recommendations to the patient issued at the end of the examination and the treatment process.
The doctor must comply with all legal aspects when completing the form.
The outpatient card consists of forms on which long-term and operational information is recorded.
The permanent information contained on the front adhesive sheets includes:
⦁ information copied from an identity document;
⦁ blood type with Rh factor;
⦁ information about past infectious diseases and allergic reactions;
⦁ final diagnoses;
⦁ results of preventive examinations;
⦁ a list of prescribed narcotic drugs.
Operational information is entered on the inserts, where the results of the initial treatment and secondary visits of the local therapist, narrow-profile doctors, and consultations with the head of the department are recorded.
Extract from the outpatient card
An extract is a medical certificate on the state of health in the form 027 / y, which belongs to the second group of medical records documentation. It contains information about past illnesses during the period of outpatient treatment.
Its purpose, as well as the entire documentation of this group, is the implementation of an operational exchange of data on the health of patients, which helps to connect the individual stages of sanitary and preventive and therapeutic measures.
An extract may be provided by the patient to the employer to inform about outpatient treatment. It is not subject to payment, but is rented together with a sick leave, if the latter is issued for more than a month.
This document allows you to 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 comply with that contained in the outpatient card.
The extract can be used to prescribe further medical procedures.
