Medical institutions include public hospitals and clinics, offices in schools and kindergartens, private clinics, maternity hospitals, dispensaries. Each institution is required to keep records of examinations, treatment measures, sanitary and hygienic and preventive measures taken. In addition, medical documentation includes accounting and reporting forms. Unified documents are fixed by the Ministry of He alth of the Russian Federation. If a particular medical institution requires its own medical documentation, then it is approved by the head physician.
Unified forms indicate the type of a particular document, format, and terms of its storage. Reporting forms must be completed correctly, reliably, in a timely manner, with maximum completeness. The standardized design of primary documentation on paper facilitates its further processing in electronic form, accounting and analysis. This, in turn, is important for planning activities, analyzing the work of personnel, assessing the volumethe work of medical institutions, the effectiveness of their activities, the provision of statistical data to regulatory authorities.
Storage of documentation is carried out in accordance with the law on medical secrecy. The information contained in it is not allowed to be disclosed to third parties, just as it is not allowed to transfer such documents to anyone. Of course, in some cases, exceptions are possible:
- Upon request, copies of the required forms, but not the originals, may be provided to the patient.
- With the consent of a person, data from his documents can be transferred for publications, research, education.
- If a citizen cannot make a decision due to a state of he alth, it is allowed to provide information without his consent only for the purpose of his treatment.
- Transmission of information to third parties is also possible in cases where there is a risk of mass spread of infectious diseases or poisoning.
- No consent is required from a minor patient to release information to their parents or guardians for further treatment.
- During legal proceedings, medical records may be released at the request of the relevant authorities.
Conditionally, all medical documentation can be divided into several types:
- Documents describing the patient's condition, diagnosis, medical appointments during the period of observation of him in one of the medical institutions. Examples include "Outpatient or inpatient charts", "History of childbirth",“Individual pregnancy card.”
- Documents that provide communication between various medical institutions As a rule, they carry information about the current condition of the patient and the need to take certain measures (for example, "Extract from the medical record").
- Documents directly reflecting the work of the medical staff ("Register of Procedures", "Register of Medicines").
It is also possible to separate all documents depending on the institutions and specialists using them. This includes, for example, the documentation of a speech therapist, gynecologist, forensic medical examination institutions, ambulance stations and others.
