Outpatient card: what is it and why is it needed?

What is an outpatient card? You will learn the answer to this question from this article. In addition, information about why such a document is created, what items it includes, etc. will be presented to your attention.

General information

An outpatient card is a medical document. In it, attending physicians keep records of the prescribed therapy and medical history of their patient. It should be noted that such a card is one of the main documents of the patient who is undergoing treatment and examination on an outpatient and outpatient basis. The form of the medical record is the same for all medical institutions. Such a document is filed for each patient upon his first visit to the hospital.

Medical record and its role in practice

The outpatient card, first of all, serves as the basis for any legal action (if any). Moreover, the correct filling of the patient’s medical history is of great educational importance for the doctor, as it strengthens his sense of responsibility. It should also be noted that this document is very often used in insured events (in case of loss of health of the insured person).

Incorrectly filled cards

If the medical record of the outpatient was not filled out accurately or was lost by the registry, then patients can present reasonable claims to the institution. By the way, in some clinics there is such practice as the intentional loss of medical records. As a rule, this happens with poor clinical outcomes, errors in prescribing medications and procedures, etc.

One of the ways to improve the safety of outpatient cards is the introduction of their electronic versions. But this method has two sides: thanks to such documents, it is quite easy to track the sequence of their changes, although the issued electronic card has no legal force.

Map Content

An outpatient medical record includes forms for prompt and long-term information. Consider their content in more detail.

1. Forms of operational information consist of formalized inserts for recording the patient's first visit to the doctor, as well as for patients with influenza, tonsillitis and acute respiratory disease. In addition, they contain inserts for a second visit, a stage epicrisis for the advisory commission. Such forms are filled in as the patient goes to the doctor at home or on an outpatient appointment, and glued to the card spine.
2. Long-term information forms contain signal marks, information about preventive examinations, record sheets of already specified diagnoses and lists of prescription of any narcotic drugs. Such inserts are usually attached to the card cover.

Basic principles of conducting maps

An outpatient card is required for:

• descriptions of the patient’s condition, outcomes of therapy, diagnostic and treatment measures, and other information;
• observing the chronology of events that affect the adoption of organizational and clinical decisions;
• reflection of physical, social, physiological and other factors that affect the patient throughout the pathological process;
• understanding and compliance by the attending doctor with all the legal nuances of their activities, as well as the importance of medical documentation;
• recommendations to the patient after completion of the examination and completion of treatment.

Card Requirements

The outpatient card must be filled in by the doctor strictly according to the rules. He must:

• fill out the title page only in accordance with order No. 255 of the Ministry of Health and Social Development of the Russian Federation of November 22, 2004;
• to reflect all patient complaints, medical history, clinical diagnosis, results of objective examination, medical and diagnostic measures, repeated consultations and information regarding the observation of the patient at the pre-hospital stage;
• fix and identify risk factors that can aggravate the severity and course of the disease, as well as the impact on its outcome;
• record the time and date of each record;
• state reasonable and objective information that will protect medical staff from possible
  
  complaints or lawsuits;
• stipulate any additions and changes indicating the date of their introduction and the signature of the doctor;
• timely refer the patient to a social examination or a meeting of the medical commission;
• justify the prescribed therapy for patients in the privileged category;
• for patients with a privileged category, provide for prescribing in triplicate, one of which must be glued to the card.

Each entry is signed only by the attending doctor with a transcript of F.I.O. Records that have nothing to do with helping this patient are not allowed. All marks in the medical record must be thoughtful, logical and consistent. Particular attention is paid to those records that were kept in complex diagnostic cases, as well as in emergency care.