Maintenance of medical records and records: rules and requirements

The maintenance of medical records and records is now an integral part of the health worker's work. In many institutions special archives have been created for papers of all kinds. Next, consider the procedure for maintaining medical records.

General information

Medical records should be understood as a system of blank forms. They are intended for recording the results of diagnostic, therapeutic, sanitary-hygienic, preventive and other measures. Medical documentation is also used in the analysis and synthesis of information.

The form

The federal-level Order "On the Maintenance of Medical Records" provides special rules for forms used in health care institutions. Most of the data is recorded in different documents. For example, it could be a case history, a study result, a prescription, a referral to a diagnosis or therapy, and so on. The maintenance of medical accounting and reporting documentation involves the completion of certain sections, drawing up tables, charts and other. Specialists should be able to fill in the prescribed standard forms.

Basic data

The maintenance of medical accounting and reporting documentation is carried out with the purpose of collecting and subsequently summarizing such information as:

• Passport and demographic information. It includes data on the name. Patient, year and place of his birth, relatives, specific activities.
• Information about the function and structure of medical institutions. They reflect the specifics of the activities of an organization. For example, it can be data about the possibility of carrying out in a particular institution of instrumental or laboratory diagnostics.
• Statistical-administrative information. It forms the basis for the subsequent counting of the state statistical statistics, as well as the parameters characterizing the activities of doctors, departments and institutions in general. Such data include, for example, the accuracy of the diagnosis in accordance with the WHO classifier, the length of the patient's stay in treatment, the level of recovery of the patient's performance, and so on.
• Planned indicators. These include information about the accounting and economic activities of institutions.

Unification of information

In all the same types of institutions, the primary medical documentation is maintained, which is established by the list, which indicates the type of document (form, journal, etc.), format and timing of its storage. Samples of registration forms and the rules for their completion are contained in the album approved by the Ministry of Health. There are certain rules for the maintenance of primary medical records. They provide for the unification of securities. Existing forms of medical records management make it much easier to process information. Approved by the Ministry of Health standard forms are adapted for mechanized analysis using computers.

Maintaining medical records and reports: main tasks

Forms filled in accordance with standards reflect the scope and nature of the activities of institutions. The maintenance of medical records in a polyclinic, for example, is necessary for the further planning of activities aimed at improving the state of health and assisting citizens. In addition, statistical information is provided to health authorities at various levels. Observing the rules of conducting primary medical documentation, specialists contribute to the formation of an adequate assessment of the effectiveness of institutions in general.

Basic standards for filling

Among the most important requirements that are imposed on the documentation are:

• Timeliness and completeness of records.
• Medical literacy.
• Reliability.

Medical records are papers that have only an official purpose. In this regard, it should be available to those who use it at a professional level.

Patient card

It is considered the main medical document. The card starts on every visitor. The nature of the pathology, the frequency and duration of visits, the diagnosis, the prescribed therapy do not have any effect on the requirements for the management of medical records. As a rule, the card is filled in every visit to the doctor. The specialist enters information about the patient's complaints, diagnosed, prescribed medications, the course of therapy and its effectiveness.

The specifics of the map

Norms for completing this document, as well as other securities of the medical institution, are set in a special order of the Ministry of Health of 2004. In particular, specialists are instructed to make data on the card both temporary and permanent. The latter include several items that must be filled in. First of all, this is the personal data of the patient. It is also necessary to compile a table of refined diagnoses. It is on the cover of the card. Information on disability and other severe pathologies is also referred to as permanent information. And, finally, the number of items that must be filled out includes the results of planned inspections. A separate card is set up for each patient in the hospital, as well as for the hospital department. A special sample is filled during evacuation.

Write epicrisis

The maintenance of medical records in a polyclinic involves not only collecting information directly in the institution that the patient visits. The card also records data about the treatment that took place outside of it. For this, a written epicrisis is used. If a person has been treated for a while in the hospital, his card, naturally, during this period was in the institution where he is on the register. Since the rules for the management of medical records oblige to include in it all information concerning the health of a citizen, an extract from his medical history is made. The discharge epicrisis is pasted into the map.

Medical records in the hospital

In addition to other documents established by the Ministry of Health, a special form is filled in this institution. It is the form 027 / y. It replaces the discharge epicrisis. The completed form 027 / y is issued directly in the hospital. This help is also used in cases where it is necessary to supplement information in one card with information from another. Such situations arise, in particular, when the patient is visited by several institutions at once. Since the rules of medical records are always binding on a patient who is not subject to removal outside the hospital or polyclinic, they are formed in this case a few.

Features of filling

In fact, the discharge epicrisis, like the 027 / y form, is a brief medical history. It is issued after discharge from the institution. Actually, therefore, the document is called - discharge. It reflects the results of treatment. Here it should be said that this document, in principle, is a kind of epicrisis in the broadest sense of the word. The latter acts as a conclusion, a certain judgment about the causes of pathology, the process and nature of therapy, changes in the patient's condition, the outcome of the treatment, and so on.

Inquiries

These documents have their own specifics. From other papers, they differ in directivity and direct communication directly with patients. The latter is due to the fact that they are formalized for the purpose of transfer to the patient for presentation at the place of demand. In the most extensive form, the help is descriptive type. However, in practice there are not so many. Usually, references have a reduced form. One of the most striking examples is the epicrisis mentioned above. Or help in the kindergarten or school.

Common fill errors

Among the most frequent violations of documentation in the institution are the following:

• Absence of justifications for hospitalization, clinical and preliminary diagnoses.
• Deficiencies in the description of complaints, objective examination, anamnesis.
• Lack of grounds for any interventions.
• Incorrect registration of records of prescribed medication.
• Lack of awareness of the patient and his voluntary consent to intervene.
• Low informative epicrisis, records of consultants, diaries.
• Absence of indications of the results of therapeutic measures.
• Non-inclusion in the document of the time of examination of the patient by a doctor or consultants, as well as data on the conduct of a surgical procedure.
• The formal nature of the information, illegibility and negligence of filling, broken chronology in the presentation of information. Absence of the signature of the attending physician or the head of the department.
• Absence of data on dynamic observation of the patient and epizootic epicrisis.

It should be noted that many descriptive documents, in particular, a discharge epicrisis or a medical history directly, require considerable effort from a specialist. Nevertheless, it is impossible to do without the procedure for filling them.

Finally

Legislation regulating the health care system is constantly being improved. International standards are taken into account, new norms are adopted concerning the filling and keeping of accounting and reporting documents in institutions. At the governmental level, the task is to provide employees with the most effective tools for collecting and summarizing data. At the same time, the state sets a goal to facilitate the work of the doctor, create conditions under which the execution of the relevant documents will not interfere with his main activity, but contribute to it. Competent management of medical records has the most important state and social significance today.