At certain intervals, the Ministry of Health issues regulatory documents that contain forms of medical documentation. They are used in all health facilities operating in the CHI system. For example, an outpatient coupon (form 025 / y-11) was approved by a ministerial order in 2003. However, in the future, in connection with the release in different years of other legal acts, the form of the coupon also changed.
general information
The current order No. 834n, which entered into force on March 9, 2015, contains the unified forms necessary for filling out by medical organizations, including the new outpatient coupon, which replaced the outpatient coupon form 025-12 / u . In addition, this document defines the procedure for filling them out. The documentation maintained by healthcare institutions is considered their responsibility in accordance with the Federal Law “On the Basics of Protecting the Health of Citizens in the Russian Federation”. Medical documentation serves as the main source of obtaining the first information about patient care, namely data on:
- treatment;
- surveys;
- rehabilitation measures;
- re-examination;
- issuance of various certificates;
- and other.
Private medical organizations are required to fill out forms, including a single outpatient coupon, approved by the above order only if they work in the compulsory medical insurance system, which is part of state social insurance.
Department of Medical Statistics
This department of the outpatient healthcare institution carries out work on the processing and collection of accounting primary documents, on the basis of which it makes the necessary reports. An outpatient coupon is considered one of the main ones. Processing, sorting and checking it is carried out on a daily basis using computer programs or manually. Reports on the results of the outpatient department are compiled monthly, quarterly and at the end of the year. They reflect information, the source of which is form 025-2 / y “Statistical coupon of an outpatient patient”. It is intended for fixing final diagnoses.
The following information on the individual is entered in this form:
- Full name;
- address;
- floor;
- in which area is the patient observed (workshop, pediatric or therapeutic);
- where does he work;
- In what area does he live;
- age;
- an updated diagnosis is entered, and a mark is made if it was established in life for the first time;
- it is indicated at which treatment (preventive examination, for the appointment of treatment, etc.) the disease was detected;
- in case of injury or poisoning, it must be clarified whether they are related to work in the workplace or received elsewhere (household, sports, school, road transport, others);
- Date of completion;
- signature of the person who contributed the information.
Form 025-1 / u "Outpatient Patient Card"
This form is an accounting form, it is issued by health facilities that carry out outpatient visits. Fill it, using computer technology or manually, medical workers for each individual who went to the clinic. The order of filling and the form of the coupon is approved by order of the Ministry of Health of Russia. Information for entering information into the coupon is obtained from a medical card, a child’s development history, a card from a pregnant or pregnant woman, and also from other medical documents. Information in the coupon is entered or one or several options are selected from those already available in this form. Abbreviations during the execution of the document are prohibited, all words should be written in full. The names of medicines can be written in Latin.
In addition, the following information is noted:
- passport data;
- each visit is marked with the date when the coupon was opened;
- about available benefits, including information about disability;
- insurance policy number;
- employment of an individual;
- purpose, date of visit to the health facility;
- ICD-10 diagnosis code, 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 accuracy and accuracy of the coupon. The correctness of filling out the coupon is checked by the statistician. In case of errors, the form is given to the doctor for revision. The coupon is stored in a health facility for a year.
Outpatient Coupon Filling Sample
When filling out form 025-1 / y, the following information is entered on the items:
- Date, month, year of treatment at a healthcare institution. This information is entered every time the patient visits the clinic.
- If an individual has the right to provide a social package (state social assistance in the form of a set of social services), then the benefit code with a digital designation is reflected.
- The end date of the granted benefit.
- The series, policy number and name of the clinic in which the patient is insured.
- SNILS.
- Passport data.
- Place of work, service or otherwise.
- If the patient is a child, then a schoolchild or preschooler is noted, and also whether he attends kindergarten.
- Disability group when it was established.
- What kind of help (primary specialized, medical health care, etc.), who was provided (general practitioner, district doctor, paramedic and others).
- Whether emergency medical care was provided during the visit.
- Which doctors, including narrow specialists, were visited by an individual.
- For what reason the patient turned to a health care institution.
- Diagnosis (preliminary, main, final).
- Prescribed medicines for citizens receiving state social assistance, i.e. a social package.
- A note on the issuance of a sick leave certificate indicating the period of incapacity for work.
- Name of the doctor, his code and specialty.
Entering information in primary medical records
Outpatient clinics fill out the outpatient's coupon with clinics that receive patients, as well as taking into account completed cases that occurred during the service period. Completed cases mean a certain amount of diagnostic and rehabilitation and rehabilitation actions as a result of which:
- the patient may be referred to a specialized or general profile healthcare institution;
- remission or recovery;
- death of an individual.
Until March 2015, an outpatient coupon (025-12 / y) was used at all health care facilities at each patient visit. Currently, a new form has been approved, in which there is information about the patient, the services rendered by doctors and nurses, illnesses or injuries, preferential prescription for a medicine, dispensary registration or temporary disability. In addition, a mark is placed on which disease is registered in the individual: acute, chronic or detected for the first time. All diagnoses are recorded in strict accordance with the International Classification of Diseases of the tenth revision.
Processing the form of the coupon of an outpatient patient approved by order No. 834n makes it possible to create a register and keep records of both the children and adults, which is served at the outpatient unit. 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 outpatient institution. In addition, indicators of the incidence of the population are calculated.
The concept of final diagnoses
An updated diagnosis of the initial treatment is recorded by the doctor in the individual’s medical record, as well as in the final diagnosis sheet. Registered for the first time, chronic diseases or occurring in an individual several times a year, for example, acute respiratory viral infections, have a specific designation. If the doctor at the first visit cannot establish the diagnosis, then only the date of the visit is indicated on the final diagnosis sheet. Further, opposite her, after conducting additional types of examinations, an updated diagnosis is entered. If several diseases are detected, they are also recorded in this sheet. For the registration of final diagnoses, the information from the record sheet of final diagnoses is entered into the statistical coupon of an outpatient. At the end of each month, completed coupons are transferred to statisticians for reporting and registries of treated patients. From the correctly filled out coupon, the following information is extracted for each service case in the outpatient facility:
- The purpose with which the individual applied: consultative, preventive examination, medical observation, medical diagnostic, medical and social, and more.
- Frequency - primary, repeated.
- How much help was provided directly at the health care facility and at home.
The finished case is when the goal of conversion is achieved. Information in the statistical coupon of an outpatient is entered directly by the attending physician. Its storage is carried out in his office until the moment when a specific case of service is completed. This procedure disciplines the doctor and motivates him to provide active assistance to the patient. Heads of departments, analyzing and checking the filling of the coupon, perform quality control of patient management. Of particular interest are cases associated with the disease, in which there were more than five visits, or cases lasting more than a month, as well as unfinished.
The need for statistical forms
For planning activities related to health care and the organization of medical care in a healthcare institution, the study and analysis of the patient population and general morbidity are of great importance. Therefore, information about all pathological processes that are identified when an individual visits the clinic regardless of their purpose is necessarily entered into the registration forms: various types of examinations, with a medical purpose, etc. In the outpatient department, a uniform procedure for registering patient appeals is adopted. Its essence is as follows.
The diagnosis is made in:
- outpatient card;
- final diagnosis sheet;
- outpatient coupon form, i.e. statistical coupon.
The entries in the updated diagnosis sheets provide an opportunity for the doctor to get acquainted with previously transferred diseases, plan preventive measures, including medical examination. A statistical coupon is the primary accounting documentation. With its help, the general incidence (level, nature) of individuals in the service area of the clinic is studied. The basic rules for filling out ambulatory patient coupons or standard coupons are as follows:
- The diagnosis, which was made at the first visit and is not in doubt, is included in the coupon.
- The presumptive diagnosis cannot be fixed in the coupon.
- If the diagnosis has changed, then the information is necessarily corrected in the standard.
- If an individual has several diagnoses, they are also recorded in the coupon. Moreover, for each pathology, a ticket is compiled.
- Diseases that are a complication of others are not subject to registration. Only the underlying disease is recorded. For example, pneumonia arose against the background of the flu. Only flu is added to the ticket.
- Next to the diagnosis made for the first time, 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 introduced into the statalon once.
- Acute - at each detection.
- If the diagnosis was specified in another medical organization, then it is registered in the institution where the individual is constantly observed.
Passport data of the patient are entered into the coupon by the registry employee, 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 outpatient unit, where form 025-1 / u “Outpatient's coupon” is currently valid.
General incidence
This concept hides the prevalence and frequency of all cases of diseases registered for the first time, for which individuals turned to the outpatient health care institution this year. In order to collect and analyze information about the general incidence, information is obtained from:
- medical records of the patient;
- statistics of final diagnoses;
- outpatient coupon.
The above documentation is filled in all outpatient facilities, including outpatient clinics in rural and urban areas. It should be noted that in specialized medical organizations, such as anti-tuberculosis, oncological or neuropsychiatric, coupons are not kept. In dispensaries dealing with skin and venereal pathologies, the ticket is filled out only for individuals suffering from diseases of the dermis. Medical organizations operating in the CHI system apply an outpatient coupon form, the form of which is approved by order of the Ministry of Health 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 diseases;
- dispensary observation (accounting);
- on temporary disability;
- about writing out a free prescription.
For one case of the disease, several coupons can be issued. 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 (first recorded, acute, chronic, exacerbation);
- information about the method for detecting the disease - at home or at the reception, with a routine examination.
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 the specific treatment, it is he who is made for this treatment.
- Of all the diseases that caused this treatment, the most severe is recorded, and all the others fit into the section of concomitant diseases.
For example, an individual has applied for therapy with an acute pathology, and it, in turn, accompanies a chronic one. In this case, the main is the first, and the second is concomitant. If the main diagnosis has been changed, then instead of the coupon of the outpatient patient that was issued initially, a new one is filled. In addition, each case of a disease registered for the first time is recorded in a sheet of records of updated diagnoses. Coupons are filled at the end of the appointment with a doctor or statistician, depending on the internal organization of the health care institution.
Filling and automated processing
Information on the outpatient’s coupon is entered by all medical organizations that use the accounting system for the completed case of care in their activities, which means performing a certain amount of diagnostic and rehabilitation procedures, the result of which is different and is represented by the following: remission, complete recovery, referral for treatment to the hospital , including specialized, day or round-the-clock stay. A fatal outcome also falls under the finished case.
Processing the coupon of an outpatient patient in a machine way, i.e. automated, makes it possible to:
- Accounting and creation of a register attached to a specific institution for medical care of the population.
- Maintaining and accounting for the compulsory medical insurance policy.
- Analysis of various databases on nosological forms.
- Formation and collection of statistical information on the medical services that were provided, prescription drugs, completed case, etc.
- The system of payments for the medical care provided in the clinic.
The processing of a new form, which replaced the coupon of an outpatient patient of form 025-12 / y, is carried out using an automated system using special statistical software modules.
Statistics in outpatient facilities
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- Twelfth - an accounting specialist needs it if the insurance company does not compensate for all injuries.
Prior to the publication of the order of the Ministry of Health of the Russian Federation No. 834n, healthcare institutions entered data on the outpatient's coupon (025-12 / y). The current form is 025-1 / y. Thus, it is advisable for the accounting service to possess knowledge of what information is entered into the coupon and how to use this information correctly.
What will happen if they did not fill out primary medical documents, in particular, an outpatient's coupon?
When receiving money from patients, a healthcare institution is required to 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. Confirm the fact of its provision is possible using the contract that is concluded between the individual and the clinic; or if the service is provided as part of the compulsory medical insurance, then under a contract with an insurance company. According to the conclusions of lawyers, a contract is a statement of intent to provide a service, and the fact of its provision must be confirmed by special documents.
The only document that confirms the actual provision of medical services is an outpatient voucher. In the case of an agreement with an insurance company, this will be an act of acceptance of services. Thus, if the coupon is not available, then the tax authorities will consider the money received from the individual as gratuitous and will not include them in the expenses for calculating income tax, that is, they will not take into account the costs of providing medical services.