Outpatient coupon: description, filling rules, sample

2024 Author: Curtis Blomfield | [email protected]. Last modified: 2023-12-16 20:44

With a certain frequency, the Ministry of He alth issues regulations that contain forms of medical documentation. They are used in all he alth care institutions operating in the CHI system. For example, the outpatient voucher (Form 025/y-11) was approved by ministerial order in 2003. However, in the future, due to the release of other legal acts in different years, the form of the coupon also changed.

General information

The current order No. 834n, which entered into force on March 9, 2015, contains unified forms required to be filled out by medical organizations, including the new outpatient coupon, which replaced the form 025-12 / y "Outpatient's card". In addition, this document defines the procedure for filling them out. The documentation maintained by he althcare institutions is considered their responsibility in accordance with the Federal Law "On the Fundamentals of Protecting the He alth of Citizens in the Russian Federation". Medicaldocumentation serves as the main source of first information about patient care, namely data on:

• treatment;
• surveys;
• rehabilitation activities;
• re-examination;
• issuance of various certificates;
• and more.

Private medical organizations are required to fill out forms, including the unified outpatient voucher approved by the above order, only if they work in the MHI system, which is part of the state social insurance.

Department of Medical Statistics

This department of a polyclinic he alth care institution is working on processing and collecting accounting primary documents, on the basis of which it makes the necessary reports. One of the main ones is the outpatient card. Processing, sorting and checking it is carried out on a daily basis using computer programs or manually. Reports on the results of the work of the polyclinic link are compiled monthly, quarterly and at the end of the year. They reflect information, the source of which is the form 025-2 / y "Statistical coupon for an outpatient". It is intended to fix the final diagnoses.

The following information for an individual is entered in this form:

• Full name;
• address;
• gender;
• where the patient is observed (shop, pediatric or therapeutic);
• where he works;
• where does he live;
• age;
• fits in updateddiagnosis, as well as a mark if it was established in life for the first time;
• indicates at what treatment (prophylactic examination, for the appointment of treatment, etc.) the disease was detected;
• in case of injury or poisoning, it is necessary to explain whether they are related to work at work or received elsewhere (household, sports, school, road transport, others);
• fill date;
• signature of the person who entered the information.

Form 025-1/u “Outpatient Card”

This form is a record, it is issued by he alth care institutions that carry out outpatient appointments. Fill it out using computer technology or manually, medical workers for each individual who applied to the clinic. The procedure for filling out and the form of the coupon itself is approved by order of the Ministry of He alth of Russia. Information for entering information into the coupon is drawn from the medical record, the history of the development of the child, the card of the woman who has given birth or the pregnant woman, as well as from other medical documents. Information is entered into the coupon or one or more options are selected from those already available in this form. Abbreviations are not allowed when drawing up a document; all words should be spelled out in full. Names of medicines can be written in Latin.

In addition, the following information is noted:

• passport details;
• at each visit, the date when the coupon was opened;
• about available benefits, including disability information;
• insurance policy number;
• employment of the individual;
• goal, date of visit to the he alth facility;
• diagnosis code according to ICD-10, the diagnosis itself is prescribed;
• data of the doctor who received the patient and provided assistance on an outpatient basis.

The doctor is responsible for the reliability and accuracy of the coupon. The correctness of filling out the coupon is checked by a medical worker involved in statistics. If errors are found, the form is given to the doctor for revision. The coupon is kept at the he alth facility for a year.

Outpatient Coupon Template

When filling out form 025-1/y, the following information is entered point by point:

1. Day, month, year of treatment in a he althcare facility. This information is entered every time the patient visits the clinic.
2. If an individual is en titled to a social package (state social assistance in the form of a set of social services), then the benefit code is displayed, which has a digital designation.
3. End date of benefit provided.
4. Series, policy number and name of the clinic where the patient is insured.
5. SNILS.
6. Passport details.
7. Place of work, service or otherwise.
8. If the patient is a child, then note the student or preschooler, and also whether he attends kindergarten.
9. Disability group when set.
10. What kind of assistance (primary specialized, medical he alth care, etc.), by whom was it provided (general practitioner, district doctor, paramedic andothers).
11. Was there any medical emergency during the visit.
12. Which doctors, including subspecialists, has the individual visited.
13. For what reason did the patient go to the he althcare facility.
14. Diagnosis (preliminary, main, final).
15. Prescribed medicines for citizens receiving state social assistance, i.e. social package.
16. Sick leave certificate indicating the period of incapacity for work.
17. Full name of the doctor, his code and speci alty.

Entering information into primary medical records

Polyclinics that receive patients, as well as taking into account completed cases that occurred during the service period, fill out an outpatient ticket. Completed cases mean a certain amount of treatment, diagnostic and rehabilitation actions as a result of which:

• the patient can be referred to a specialized or general he althcare facility;
• remission or recovery;
• death of an individual.

Until March 2015, an outpatient voucher (025-12/y) was used at every visit to a patient in all he althcare facilities. Currently, a new form has been approved, in which there is information about the patient, the services provided by medical and paramedical personnel, diseases or injuries, a preferential prescription for a drug, dispensary registration or temporary disability. In addition, a note is made about which disease is registered inindividual: acute, chronic or detected for the first time. All diagnoses are recorded in strict accordance with the Tenth Revision of the International Classification of Diseases.

Processing the outpatient coupon form approved by Order No. 834n makes it possible to form a register and keep records of both the child and adult population, which is served in the outpatient clinic. Thanks to the automated processing of primary statistical medical documents, a report is generated for the previous year of work, which contains information about diseases registered in patients and living in the service area of the polyclinic institution. In addition, the incidence rates of the population are calculated.

The concept of final diagnoses

The corrected diagnosis regarding the initial visit is recorded by the doctor in the individual's medical record, as well as in the final diagnosis record sheet. Registered for the first time, chronic diseases or those that occur in an individual several times a year, for example, SARS, have a specific designation. If the doctor at the first visit cannot establish a diagnosis, then only the date of the visit is indicated in the final diagnosis record sheet. Further, opposite it, after additional types of examinations, a refined diagnosis is entered. If several diseases are detected, they are also recorded in this sheet. Information from the final diagnosis record sheet is entered into the statistical coupon of an outpatient for the registration of final diagnoses. ATat the end of each month, the completed coupons are transferred to statisticians for the formation of reports and registers of treated patients. From a correctly completed coupon, the following information is extracted for each case of service in an outpatient type institution:

• The purpose for which the individual applied: advisory, preventive examination, dispensary observation, treatment and diagnostic, medical and social, and more.
• Periodicity - primary, repeated.
• How much care was provided directly in the he alth facility and at home.

The completed case is when the goal of the appeal has been reached. Information in the statistical coupon of an outpatient is entered directly by the attending doctor. It is stored in his office until the moment when a specific case of service is completed. Such an order disciplines the doctor and motivates him to provide active assistance to the patient. Heads of departments, analyzing and checking the filling of the coupon, control the quality of patient management. Of particular interest are disease-related cases with more than five visits, or cases lasting over a month, and those that are not completed.

Need to maintain statistical forms

For planning activities related to he alth protection and the organization of medical care in a he althcare institution, the study and analysis of patient populations and general morbidity is of great importance. Therefore, in the accounting forms it is necessaryinformation is entered on all pathological processes that are identified when an individual visits a polyclinic, regardless of their purpose: various types of examinations, for therapeutic purposes, etc. A unified procedure for registering patients' appeals is adopted in the outpatient-polyclinic link. Its essence is as follows.

The established diagnosis is entered into:

• outpatient card;
• list of final diagnoses;
• outpatient voucher form, i.e. statistical voucher.

The records available in the lists of updated diagnoses provide an opportunity for the doctor to get acquainted with previously transferred diseases, plan preventive measures, including clinical examination. The statistical coupon is the primary accounting documentation. With its help, the general morbidity (level, nature) of individuals in the service area of the polyclinic is studied. The basic rules for filling out outpatient coupons or statistical coupons are as follows:

• The diagnosis, which was made at the first visit and without any doubt, is entered into the ticket.
• The presumptive diagnosis is not subject to registration in the coupon.
• If the diagnosis has changed, then the information must be corrected in the statistics card.
• If an individual has several diagnoses, they are also recorded in the coupon. Moreover, each pathology has its own ticket.
• Diseases that are a complication of others are not subject to registration. Only the underlying disease is entered. For example, pneumonia arose against the background of the flu. Only the flu is included in the ticket.
• Next toFor the first time diagnosed, the doctor puts the following designation: a (+) sign, and if the pathology has already been identified earlier, then a (-) sign is put in the coupon.
• Chronic pathologies are entered into the statistics card once.
• Acute - at each detection.
• If the diagnosis was clarified in another medical organization, then it is registered in the institution where the individual is constantly observed.

The patient's passport data is entered into the coupon by the receptionist, then it is transferred to the doctor. It is important to remember that hospitals do not participate in filling out statistical coupons. This responsibility is assigned to the polyclinic link, where the current form 025-1 / y "Coupon of the outpatient patient" is currently valid.

General incidence

Behind this concept lies the prevalence and frequency of all cases of diseases registered for the first time, for which individuals applied to a polyclinic he althcare facility this year. In order to collect and analyze information about the general incidence, information is drawn from:

• of the patient's medical record;
• stattalon of final diagnoses;
• outpatient coupon.

The above documentation is filled in all polyclinics, including outpatient clinics in rural and urban areas. It should be noted that coupons are not kept in specialized medical organizations, such as anti-tuberculosis, oncological or neuropsychiatric organizations. ATdispensaries dealing with skin and venereal pathologies, a coupon is filled out only for individuals suffering from diseases of the dermis. Medical organizations operating in the CHI system use the outpatient voucher form, the form of which is approved by order of the Ministry of He alth of the Russian Federation No. 834n.

It contains information:

• about the patient;
• about the services provided by medical workers (doctor and paramedical staff);
• about traumatic conditions and illnesses;
• dispensary observation (registration);
• about temporary disability;
• about getting a free prescription.

Several coupons can be issued for one case of illness. It must be remembered that diagnoses are entered into the documentation in strict accordance with the International Classification.

In addition, the following information is recorded:

• the course and nature of the pathology (for the first time registered, acute, chronic, exacerbation);
• information about the method of detecting the disease - at home or at the reception, during a preventive examination.

Let's consider the rules for filling out an outpatient coupon when entering information in the columns about the diagnosis:

• The main diagnosis is the one that caused a particular appeal, it is he who is entered for this appeal.
• Of all the diseases that caused this appeal, the most severe is recorded, and all the rest fit into the comorbidities section.

For example, an individual seeks therapy with an acute pathology, which in turn accompanies a chronic one. In this case, the main is the first, and the second is the accompanying. If the main diagnosis has been changed, then a new one is filled in instead of the outpatient coupon that was originally issued. In addition, each case of a disease registered for the first time is recorded in a sheet of records of clarified diagnoses. Vouchers are filled at the end of the appointment by a doctor or statistician, depending on the internal organization of the work of a he althcare institution.

Filling and automated processing

Information in the outpatient ticket is entered by all medical organizations that use the accounting system for the completed service case in their activities, which means the performance of a certain amount of diagnostic and rehabilitation manipulations, the result of which is different and is represented by the following: remission, complete recovery, referral to a hospital for treatment, including a specialized, day or round-the-clock stay. Fatality also falls under the completed case.

Processing an outpatient ticket by machine, i.e. automated, makes it possible to:

• Accounting and creation of a register attached to a specific institution for medical care of the population.
• Maintenance and accounting of the CHI policy.
• Analysis of various databases by nosological forms.
• Formation and collection of statistical information on medical services that were provided,prescribed medications, completed case, etc.
• Payment system for medical care provided at the polyclinic.

The processing of the new form, which replaced the outpatient coupon form 025-12/y, is carried out using an automated system using special statistical software modules.

Statistics in outpatient clinics

In outpatient clinics, all problems and conditions that are related to he alth and were identified when an individual contacts a doctor are subject to mandatory coding and registration. Their accounting is carried out in special medical documents, which are called primary, the information contained in them about diseases or other conditions that have any relation to he alth is transferred to the office or department of medical statistics of a polyclinic institution. The rules for coding and registration of morbidity in institutions providing outpatient care are regulated by the International Classification of Diseases of the Tenth Revision, as well as instructions and documents of the Ministry of He alth of the Russian Federation. The main accounting documents of primary medical documentation include the form of an outpatient coupon. Based on it and other reporting forms, statistical reporting indicators are developed that are used to analyze the activities of an outpatient clinic.

They can be divided into the following groups:

• staffing;
• volume of outpatient care;
• burden on medical staff;
• preventive work.

A sample of an outpatient ticket, as well as other medical documentation, can be obtained from the he alth authorities of the subject.

What information from an outpatient ticket is needed for an accountant of a medical organization

The accounting service of the he alth facility also takes part in checking the correctness of the outpatient coupon.

The following lines will be especially interesting for an accountant:

• Second and third, which contain information about the doctor who saw the individual.
• The fourth, which reflects the type of payment for the service provided. Moreover, only one source of payment should be marked in one coupon. if there are more, then several coupons are filled.
• Fifth, it provides information about where the medical service was provided.
• Sixth - the purpose for which the individual went to the clinic.
• Seventh - the result of treatment, which is entered after the last visit. If this line is not filled in, then this indicates that the service has not been provided, therefore, it is impossible to reduce taxable income on direct expenses for this service.
• Nine - the information contained in this line is necessary for the accountant when issuing a certificate of payment for the service.
• Twelfth - needed by an accounting specialist if the treatment of not all injuries is reimbursed by the insurance company.

Before the issuance of the orderMinistry of He alth of the Russian Federation No. 834n, he alth care institutions entered data into the coupon of an outpatient (025-12 / y). The current form is 025-1/y. Thus, it is desirable for the accounting service to have knowledge of what information is entered in the coupon and how to use this information correctly.

What happens if you do not fill out primary medical documents, in particular, an outpatient coupon?

When receiving money from patients, the he alth care institution must prove that this is income for the medical services provided. Only in this case, the income is reduced by the amount of costs associated with the provision of services. It is possible to confirm the fact of its provision using a contract that is concluded between the individual and the clinic; or if the service is provided within the framework of compulsory medical insurance, then under an agreement with an insurance company. According to the conclusions of lawyers, a contract is a statement of intention to provide a service, and the actual fact of its provision must be confirmed by special documents.

The only document that confirms the actual provision of medical services is an outpatient ticket. In the case of an agreement with an insurance organization, this will be an act of acceptance of services. Thus, if there is no coupon, the tax authorities will consider the money received from the individual as gratuitous and will not include it in expenses for calculating income tax, i.e., they will not take into account the costs of providing medical services.