Medical institutions include state hospitals and clinics, classrooms in schools and kindergartens, private clinics, maternity hospitals, dispensaries. Each institution is obliged to keep records of examinations, medical measures, taken sanitary-hygienic and preventive measures. In addition, medical documentation includes accounting and reporting forms. The unified documents are fixed by the Ministry of Health of the Russian Federation. If a particular medical institution requires its own medical documentation, then it is approved by the head physician.
In unified forms, the type of a specific document, the format, and the periods of its storage are indicated. Reporting forms must be completed competently, reliably, in a timely manner, with maximum completeness. The standardized preparation of primary documentation on paper makes it easier for its further processing in electronic form, accounting and analysis. This, in turn, is important for planning activities, analyzing the work of staff, assessing the workload of medical institutions, the effectiveness of their activities, and providing statistical data to regulatory authorities.
Storage of documentation is carried out in accordance with the law on medical confidentiality. The information contained in it is not allowed to be disclosed to third parties in the same way 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 may be issued to the patient, but not the originals.
- With the consent of a person, data from his documents can be transferred for publication, research, training.
- If a citizen cannot make a decision because of his state of health, it is allowed without his consent to provide information only for the purpose of his treatment.
- The transfer of information to third parties is also possible in cases where there is a danger of mass spread of infectious diseases or poisoning.
- The consent of the minor patient to the transfer of information to his parents or guardians for further treatment is not required.
- During a trial, medical records may be provided at the request of the appropriate authorities.
Conditionally, all medical documentation can be divided into several types:
- Documents that describe the patient’s condition, diagnosis, medical appointments during the observation period in one of the medical institutions. Examples include “Outpatient or inpatient patient cards,” “History of childbirth,” and “Individual card for a pregnant woman.”
- Documents providing communication between various medical institutions As a rule, they carry information about the current state of the patient and the need for certain measures (for example, "Extract from a medical record").
- Documents that directly reflect the work of medical personnel (“Journal of the accounting of procedures”, “Journal of the accounting of medical products”).
You can also divide all the documents depending on the institutions and specialists using them. This includes, for example, documentation of a speech therapist, gynecologist, forensic medical institutions, emergency medical stations and others.