CATEGORIES:
BiologyChemistryConstructionCultureEcologyEconomyElectronicsFinanceGeographyHistoryInformaticsLawMathematicsMechanicsMedicineOtherPedagogyPhilosophyPhysicsPolicyPsychologySociologySportTourism
FINAL (VERIFIED) DIAGNOSES LISTYakovleca E. V. ß47 Filling in outpatient medical card: methodical recommendations (suggested method) / E.V. Yakovleva, R. V. Khursa, V.V. Droschenko – Minsk: BSMU, 2016. – c. Provides guidance and recommendations on filling in of academic outpatient medical record. Designed for 4th year students.
ÓÄŹ 616-08-039.57-07 (091) (075.8)
© E.V.Yakovleva, R.V. Khursa, V.V. Droschenko, 2016 © EI “Belarusian State Medical University”, 2016
INTRODUCTION Practical skills in filling in medical documentation and consolidation of these skills is one of the main directions of the educational process at the Department of Outpatient Internal Medicine. The most important document of outpatient practice physician is "Outpatient medical card" (“Outpatient medical card” also often unofficially referred to as an “outpatient card”, “patient’s card” or simply “the card”) approved by the Ministry of Health of the Republic of Belarus as form # “025 / y-07”. This document is a medical passport reflecting the state and dynamics of patient’s health over a long period of time. It provides a holistic view of the patient and allows doctors of various specialties, who manage this patient during his life, to make appropriate medical decisions. Outpatient practice doctors, especially district therapists/general practitioners, are those who are responsible for the correct filling in and management of the “Outpatient medical card”.Outpatient medical card as an approved (mandatory, single) form has the following sections: passport data part, final (verified) diagnoses list, additions to anamnesis; periodic examinations, sheets for physician’s records. However, the time passed since the date of approval of the form # “025 /y-07” showed the need of addition of new sections that would meet actual practical health care needs. Therefore, now the "Outpatient Medical record" has the following structure:
· Passport data part · Final (verified) diagnoses list · Periodic (annual) examinations · Examination results · Vaccination record · Gynaecological examinations record (gynaecologist) for women · Temporary disability record · X-ray examinations record · Anamnesis · Additions to anamnesis · Physician’s records Results of laboratory (full blood count, urinalysis, blood chemistry etc) and other diagnostic tests (ECG, pulmonary function tests, ultrasound, etc), consultative clinics and diagnostic centres specialist consultations conclusions, hospital epicrises (hospital discharge records) are pasted in at the end of the outpatient card or together with the physician’s records.
PASSPORT DATA PART Patient’s name Sex, Date of Birth Phone number (home, work) Patient’s address Place of employment, name and nature of manufacture. Occupation Group of Dispensary surveillance. Indicate diagnosis for groups III and IV.
Data that is indicated on this page should include: allergic anamnesis, history of viral hepatitis, weather the patient belongs to the group of citizens who are eligible for benefits (e.g. military actions handicapped, patients with 1st 2nd 3rd group disability, prisoners of concentration camps, etc) with the certifying document number, series and batch; in case of an elderly patient living alone - contact information of the nearest relatives, acquaintances or assigned social service worker should be noted.
FINAL (VERIFIED) DIAGNOSES LIST In this part the exact date (day, month, year) of the patient’s visit is specified, the final (specified) diagnoses is briefly formulated and confirmed by physician’s signature. First-time diagnoses (diagnoses established for the first time) are marked with “+”, chronic diagnoses are repeatedly indicated every year, acute conditions (e.g. acute upper respiratory tract infections) are marked with “+” every time. The data given here allows the physician to know the patient’s pathology and the reason of the patient's visit, decide whether filling of a statistical coupon is required (remember that statistical coupon is filled in all cases of acute illness , and only once a year in case of chronic pathology).
Date: 2016-04-22; view: 934
|