What is an outpatient card? You will learn the answer to this question from this article. In addition, your attention will be presented with information about why such a document is being created, what items it includes, etc.
General information
Outpatient card is a medical document. In it, the attending physicians keep records of the prescribed therapy and the medical history of their patient. It should be noted that such a card is one of the main documents of a patient who is undergoing treatment and examination on an outpatient and outpatient basis. The form of the medical card is the same for all medical institutions. Such a document is created for each patient at his first visit to the hospital.
Medical record and its role in practice
The outpatient card is primarily the basis for any legal action (if any). Moreover, the correct filling of the patient's medical history is of great educational importance for the doctor, as it strengthens his sense of responsibility. It should also be noted that this document is veryoften used in insurance cases (in case of loss of he alth of the insured person).
Misfilled cards
If an outpatient's medical record was filled out incorrectly or was lost by the registry, then patients can make reasonable claims to the institution. By the way, in some clinics there is such a practice as the deliberate loss of medical records. This usually happens with poor clinical outcomes, errors in prescribing medications and procedures, etc.
One of the means to improve the safety of outpatient cards is the introduction of their electronic versions. But this method has two sides: thanks to such documents, it is quite easy to track the sequence of their changes, however, the issued electronic card has no legal force.
Card content
The outpatient medical record includes forms for operational and long-term information. Consider their content in more detail.
- The operational information forms consist of formalized inserts for recording the first visit of a patient to a doctor, as well as for patients with influenza, tonsillitis and acute respiratory disease. In addition, they contain inserts for a return visit, a milestone epicrisis for the advisory committee. Such forms are filled in as the patient contacts the doctor at home or at an outpatient appointment, and are glued to the spine of the card.
- Long-term information forms contain signalmarks, information about preventive examinations, lists of records of already specified diagnoses and sheets for prescribing any narcotic drugs. These inserts are usually attached to the cover of the card.
Basic principles of card keeping
Outpatient card required for:
- descriptions of the patient's condition, outcomes of therapy, treatment and diagnostic measures and other information;
- observance of the chronology of events that influence the adoption of organizational and clinical decisions;
- reflections of physical, social, physiological and other factors influencing the patient throughout the pathological process;
- understanding and compliance by the attending doctor with all the legal nuances of their activities, as well as the significance of medical documentation;
- recommendations to the patient after the completion of the examination and the end of treatment.
Card requirements
Outpatient card must be filled out by a doctor strictly according to the rules. He must:
- fill in the title page only in accordance with Order No. 255 of the Ministry of He alth and Social Development of the Russian Federation dated 2004-22-11;
- reflect all complaints of the patient, medical history, clinical diagnosis, results of an objective examination, medical and diagnostic measures, repeated consultations and information regarding the observation of the patient at the prehospital stage;
- record and identify risk factors that can aggravate the severity and course of the disease, as well as the impact on its outcome;
- fixtime and date of each entry;
- provide reasonable and objective information that will ensure the protection of medical staff from possible
- negotiate any additions and changes, indicating the date of their introduction and the signature of the doctor;
- timely refer the patient to a social examination or a meeting of the medical commission;
- justify prescribed therapy for beneficiary patients;
- for patients of the privileged category, provide for the issuance of prescriptions in three copies, one of which must be pasted into the card.
complaints or lawsuits;
Each entry is signed only by the attending doctor with a transcript of his full name. Recordings that have nothing to do with the care of this patient are not allowed. All marks in the medical record must be thoughtful, logical and consistent. Particular attention is paid to those records that were kept in complex diagnostic cases, as well as in the provision of emergency care.
