Maintaining medical records and records today is an integral element of the work of a health worker. Many institutions have created special archives for papers of various kinds. Next, consider the procedure for maintaining medical records.
General information
Medical documentation should be understood as a system of forms of an established form. 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 Order “On maintaining medical records” adopted at the federal level provides for special rules for forms used in healthcare facilities. Most of the data is recorded in different documents. For example, it can be a medical history, the result of a study, a prescription, a referral for diagnosis or therapy, and so on. Maintaining medical accounting and reporting documentation involves filling out certain sections, drawing up tables, diagrams and other things. Professionals should be able to fill out the standard forms provided.
Basic data
Medical records are maintained for the purpose of collecting and subsequently summarizing information such as:
- Passport and demographic information. It includes data on the full name patient, year and place of his birth, relatives, specifics of activity.
- Information about the function and structure of medical facilities. They reflect the specific activities of an organization. For example, this may be data on the possibility of conducting instrumental or laboratory diagnostics in a particular institution.
- Statistical management information. It forms the basis for subsequent calculations of state medical statistics, as well as parameters characterizing the activities of doctors, departments and institutions as a whole. Such data include, for example, the accuracy of the diagnosis in accordance with the WHO classifier, the duration of the patient’s stay on treatment, the level of recovery of the patient’s health, and so on.
- Planned indicators. These include information about the accounting and economic activities of institutions.
Data Unification
In all the institutions of the same type, primary medical documentation is maintained, which is established by the list, which indicates the type of document (form, journal, etc.), the format and timing of its storage. Samples of registration forms and rules for filling them out are contained in the album, approved by the Ministry of Health. There are certain rules for maintaining primary medical records. They provide for the unification of securities. Existing forms of maintaining medical records can significantly facilitate the processing of information. The standard forms approved by the Ministry of Health are adapted for computerized analysis.
Maintaining medical accounting and reporting documentation: main tasks
Forms filled in accordance with the standards reflect the volume and nature of the institutions. Maintaining medical documentation in the clinic, for example, is necessary for the further planning of activities aimed at improving health and providing assistance to citizens. In addition, statistical information is provided to health authorities at various levels. Observing the rules of maintaining primary medical documentation, specialists contribute to the formation of an adequate assessment of the effectiveness of the institutions as a whole.
Basic filling standards
Among the most important requirements that are presented to record keeping include:
- Timeliness and completeness of entries.
- Medical literacy.
- Credibility.
Medical records are papers that are for official use only. In this regard, it should be available to those who use it on a professional level.
Patient Card
It is considered the main medical document. A card is created for each 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 maintaining medical records. As a rule, the card is filled out at each visit to the doctor. The specialist enters into it information about the patient's complaints, the diagnosis, the prescribed drugs, the course of therapy and its effectiveness.
Card Specifics
The rules for filling out this document, as well as other papers of the medical institution, are set in a special Order of the Ministry of Health of 2004. In particular, specialists are instructed to enter data on the card, both temporary and permanent. The latter include several items that are required to be filled. First of all, this is the patient’s personal data. It is also necessary to compile a table of specified diagnoses. It is on the cover of the card. Permanent information also includes information on disability and other serious pathologies. And finally, the items that are required to be filled out include the results of scheduled inspections. A separate card is set up for each sick hospital, as well as the hospital ward. A special sample is filled during evacuation.
Prescribed Epicrisis
Maintaining medical documentation in the clinic involves not only collecting information directly in the institution that the patient visits. The card also contains data on the treatment that took place outside of it. An epicrisis is used for this . If a person underwent treatment in a hospital for some time, then his card, of course, during this period was in the institution where he is registered. Since the rules of maintaining medical documentation oblige to include in it all information relating to the health of a citizen, an extract is made from his medical history. A written epicrisis is glued to the card.
Maintaining medical records in a hospital
In addition to other papers established by the Ministry of Health, a special form is filled in at this institution. It is form 027 / y. It replaces the discharge epicrisis. The completed form 027 / y is issued directly in the hospital. This certificate is also used in cases when it is necessary to supplement the information in one card with information from another. Such situations arise, in particular, when the patient visits several institutions at once. Since the rules for maintaining medical documentation oblige always to have a card on the patient that cannot be taken outside the hospital or polyclinic, several of them will be formed in this case.
Filling Features
Essentially, discharge epicrisis, like form 027 / y, is a brief history of the disease. It is issued after discharge from the institution. Actually, that’s why the document is called - an extract. It reflects the results of treatment. It should be said here that this document, in principle, is a kind of epicrisis in the broad sense of the word. The latter acts as a conclusion, a certain judgment regarding the causes of the pathology, the process and nature of therapy, changes in the patient's condition, treatment outcomes, and so on.
References
These documents have their own specifics. From other papers, they differ in orientation and direct connection directly with patients. The latter is due to the fact that they are executed in order to be transferred to the patient for presentation at the place of demand. In the most expanded form, descriptive type references are compiled. However, in practice there are not so many of them. Inquiries are usually abbreviated. As one of the striking examples, we can cite the above epicrisis. Or help to kindergarten or school.
Common fill errors
Among the most common violations of documentation in the institution are the following:
- Lack of justification for hospitalization, clinical and preliminary diagnoses.
- Shortcomings in the description of complaints, objective examination, anamnesis.
- Lack of grounds for any interventions.
- Incorrect registration of prescribed drug therapy.
- Lack of awareness of the patient and his voluntary consent to the intervention.
- Low information content of epicrisis, records of consultants, diaries.
- The lack of indications of the results of therapeutic measures.
- Failure to include in the document the time of examination of the patient by a doctor or consultants, as well as data on the surgical intervention.
- The formal nature of the specified information, illegibility and carelessness of filling, broken chronology in the presentation of information. Lack of signature of the attending physician or department head.
- Lack of data on dynamic observation of the patient and staged epicrisis.
It should be noted that many descriptive documents, in particular, discharge epicrisis or the medical history itself, require considerable efforts from the specialist. Nevertheless, it is impossible to do without the procedure for filling them out.
Finally
The legislation governing the health sector is constantly being improved. International standards are taken into account, new standards are adopted regarding the completion and maintenance of accounting and reporting documents in institutions. At the government level, the goal is to provide workers 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, to create conditions under which the preparation of relevant documents will not interfere with his main activity, but contribute to it. The competent management of medical records is of the greatest state and social importance today.