Doctors will be required to show records in the medical record.

On November 27, 2016, the order of the Ministry of Health came into force, according to which medical workers must show, at the request of the patient, all the entries that were made in his medical documents, Izvestia. The patient must receive his medical card within 30 days, and he will be able to familiarize himself with the records in it in a specially designated room.

Experts note that currently the legislation does not limit the patient in any way in his desire to receive his medical documentation. He can do this by writing an application addressed to the chief physician medical institution. However, specific terms have not been determined, and doctors are very reluctant to do this, suspecting that the patient is dissatisfied with the treatment and may make any claims against the doctor. With the entry into force of the aforementioned order of the Ministry of Health, a doctor will no longer be able to refuse a patient to receive his medical card.

Many experts note that 30 days to obtain medical documentation is too long, especially in cases where there is a need to verify the correctness of the diagnosis. Although, in their opinion, the very fact that it became possible, as stipulated by law, to check records in medical records is already a big step towards respecting the rights of the patient. Although the president of the League of Patient Defenders, Alexander Saversky, is convinced that the patient has the right to familiarize himself with the records in his medical records and test results on the day of treatment. “An outpatient card is a kind of safe in which the patient’s personal information is stored,” he notes, “The patient cannot wait 30 days! There are vitally important situations when you need to look at test results to clarify the diagnosis, get a second opinion private clinic or in the federal medical center».

Most doctors are not embarrassed by this innovation and are ready to promptly provide patients with original documents. As a rule, there are not so many such requests, and the resolution of such issues usually does not take more than a few days. “If a person needs to see the original documents, we are ready to promptly provide them. In a separate room, for example in the resident’s room, let him look,” says the head physician of the Children’s City clinical hospital them. FOR. Bashlyaeva Ismail Osmanov.

But when visiting the clinic, according to the new order of the Ministry of Health, the patient has the right to access the records in his outpatient card made medical worker, directly during the reception or immediately after it. Alexander Saversky says that this is very important measure, but not enough. He believes that the patient should have the opportunity not only to familiarize himself with the prescribed treatment, but also to confirm his agreement with it by signing the card. This, in his opinion, will be a plus not only for the patient, but also for the doctor, ensuring their safety in the event of conflict situations.

The order of the Ministry of Health also notes that not only the patient himself, but also his legal representatives - parents of minor children, guardians and trustees of incapacitated or partially capable people - can familiarize themselves with the medical documentation. According to Saversky, this is a very narrow segment of people, because There are cases when with information in medical card it is necessary for close relatives of the patient to become familiar with it, for example, when he is in in serious condition. In addition, according to this order, representatives of the patient by proxy cannot be allowed to access information about the patient’s condition. All this will be a reason to appeal this order Ministry of Health in the Supreme Court, said the president of the League of Patient Defenders.

Patients will be able to receive their medical records within 30 days, and they will be able to review them in a specially designated room. Experts say 30 days is too long long term, if we are talking about the need to check the correctness of the diagnosis. But the ability to immediately read a doctor’s notes is a big step towards respecting patient rights.

A member of the public council of the Ministry of Health, Sergei Lazarev, told Izvestia that according to current legislation, a patient has the right to receive medical documentation reflecting his state of health upon application addressed to the head physician. But specific dates have not been determined.

As you know, doctors are now very reluctant to issue outpatient cards, because if the patient wants to receive it, then there are claims against the doctor. Lazarev explained that within 30 days the medical staff will be able to correct the shortcomings in the card.

But the president of the League of Patient Defenders considers the rule establishing that medical institutions must organize a separate room in which the patient can review the documentation a plus. But he notes that the order does not set out the requirements for the premises, so most likely it will be a fenced-off part of the hall or reception area.

The order also states that familiarize yourself with medical documents, reflecting the patient’s health status, can only be done by the patient himself or his legal representative. According to Alexander Saversky, this means that the patient’s representatives by proxy are not allowed access to information. That is outpatient card In addition to the patient himself, they can be issued to parents of minor children, guardians and trustees of incapacitated or partially incompetent citizens.

What do Ryazan patients think about this? Progorod62 managed to talk with people who often go to “visit” Ryazan clinics:

I often go to the clinic because of illnesses and I noticed this: most often the doctors do not talk to me at all, but simply silently write something on the card. The idea that medical records can be looked at is good, but it would be even better if the doctor wrote more clearly or explained what he wrote on the card, said Victoria Zhurova.

I think a room where you can view medical records would be suitable for older people. They often don’t understand what doctors write. Although, as far as I know, in Ryazan there are no particular problems with receiving a card in hand,” Elena Eliseeva shared.

In my opinion, this is unlikely to spread to Ryazan, because our doctors are unique. It seems to me that they will argue with the patient and will not give the card to read. But this is purely my opinion, in no case do I want to say anything against such an idea. On the contrary, it will be even easier for the sick,” said Natalya Sventitskaya.

By the way, the League of Patient Advocates intends to appeal the order of the Ministry of Health in the Supreme Court.

On November 27, the order of the Ministry of Health comes into force, according to which doctors, at the request of the patient, must show him the notes they made during the appointment. Patients will be able to receive their medical records within 30 days, and they will be able to review them in a specially designated room. Experts say 30 days is too long when it comes to testing whether a diagnosis is correct. But the ability to immediately read a doctor’s notes is a big step towards respecting patient rights.

“Doctors are very reluctant to issue outpatient cards, because if the patient wants to receive a card, it means there are claims,” Lazarev explained. He said that there will always be reasons to find fault with a doctor’s work, for example, a diagnosis recorded late, and within 30 days the medical staff will be able to correct all the shortcomings in the chart.

The President of the League of Patient Advocates, Alexander Saversky, is convinced that the patient has the right to see his medical history and the results of his tests on the day of treatment. He emphasizes that medical records belong to medical institutions, but the owners of the information contained in them are patients.

“An outpatient card is a kind of safe in which the patient’s personal information is stored,” said Alexander Saversky. — A patient cannot wait 30 days! There are vital situations when you need to look at test results to clarify the diagnosis, get a second opinion in a private clinic or at a federal medical center,” he added.

Doctors are not embarrassed by this innovation.

— If a person needs to see the original documents, we are ready to promptly provide them. In a separate room, for example in the resident’s room, let him look,” said the head physician of the Children’s City Clinical Hospital named after. FOR. Bashlyaeva Ismail Osmanov. According to him, patients rarely ask to see medical documentation and, as a rule, in his hospital the resolution of such issues takes no more than a couple of days.

Another rule concerns the appointment at the clinic. The order states that when providing primary health care in outpatient setting the patient has the right to review the notes made by the medical professional in the medical documentation during the appointment.

“Immediately after the appointment, a person will be able to read what the doctor wrote in his outpatient card. This is a very important measure in terms of respecting the rights of the patient, but it is not sufficient,” says Alexander Saversky. He believes that the patient should confirm agreement with the prescribed treatment and sign directly on the card. And although doctors are unlikely to be delighted, this can provide them with safety in the event of a conflict situation.

But Sergei Lazarev, a member of the public council of the Ministry of Health, has a completely different opinion.

— Medical documentation- This internal document clinics. Well, what can a patient understand from a doctor’s notes? Our medicine is now completely focused on the patient, even if you treat with spells, the main thing is that he is happy,” says Lazarev.

The order also states that only the patient himself or his legal representative can review medical documents reflecting the patient’s health status. According to Alexander Saversky, this means that the patient’s representatives by proxy are not allowed access to information. That is, an outpatient card, in addition to the patient himself, can be issued to parents of minor children, guardians and trustees of incapacitated or partially incompetent citizens.

— This is a very narrow segment. There are cases when the patient is in a very serious condition and it is necessary for a relative to go and look at the necessary information in the medical history,” says Alexander Saversky. He told Izvestia that the League of Patient Defenders intends to appeal the order of the Ministry of Health in the Supreme Court.

Doctors will be required to show patients notes made during the appointment. Doctors will have to do this at the patient’s first request. The order of the Ministry of Health comes into force on November 27.

Russian doctors: between the hammer and the patient

Patients will be able to receive their medical cards in their hands within 30 days. You can view them in a specially designated place. Meanwhile, experts say that the period established by the order—30 days—is too long. Especially if we're talking about about checking the correctness of the diagnosis. However, the ability to immediately read what the doctor wrote down in the chart is a big step in terms of respecting the rights of patients, experts believe.

Now patients can look through their chart by writing an application addressed to the chief physician of the medical institution. There are no deadlines established by law. As Izvestia writes with reference to Sergei Lazarev, a member of the public council of the Ministry of Health, medical cards are now being given to patients reluctantly. After all, if a person asks for it, it means he has some claims. And there will always be reasons why you can find fault with the work of doctors. Moreover, within 30 days, the hospital staff will be able to correct all the shortcomings in the card.

Experts say patients have every right look at the entries in the card immediately after the appointment. After all, despite the fact that the cards themselves belong to healthcare institutions, the data they contain belongs to patients. Waiting 30 days in some situations is simply impossible. There are times when it is necessary to urgently look at the results of tests performed in order to later clarify the diagnosis in another, for example, a private clinic.

According to the new rules, patients will be able to read the entries in the chart immediately - right during the appointment - when providing primary health care in an outpatient setting. By the way, in the medical community there have already been proposals to oblige patients to also sign what they read, thus expressing their agreement with the diagnosis and treatment. Let us recall that earlier Pravda.Ru wrote that with next year doctors to see one patient for no more than 24 minutes.

Either the patient personally or his legal representative will be able to review the documents. That is, either parents of minors, or guardians and trustees of incompetent patients. However, the League of Patient Advocates intends to appeal this in court. They believe that it is necessary to expand the list of persons who can access the patient’s card if he is in a very serious condition, and it is urgent to look at the information in the card.

But experts believe that the rule obliging medical institutions to organize special rooms in hospitals so that people can familiarize themselves with the maps is correct. True, the order of the Ministry of Health does not stipulate any requirements for such premises, so, most likely, this will be a fenced part of the hall or reception area.

The doctors themselves are not at all frightened by the innovation. According to doctors, now patients very rarely ask for their cards to read what doctors write on them.