Clinical examination, or dispensary observation, is a method of monitoring the health status of certain groups of people. These events are characterized by the frequency and accuracy of the conduct. They are needed to clarify laboratory, radiological and other results of examinations conducted by persons registered in the dispensary.
Clinical examination of healthy persons
The opinion that only sick people are subject to medical examination is erroneous. Those who do not suffer from any diseases are also observed by specialists with a certain frequency.
Among healthy people, the following persons undergo medical observation :
- all children until they reach the age of 14;
- conscripts of military service;
- students of schools, colleges, higher educational institutions;
- workers of children's institutions;
- food or utility workers;
- working and unemployed women after 30 years;
- medical workers;
- invalids of the Second World War, labor veterans.
The goal of observing healthy individuals is to maintain their ability to work at a high level, maintain their health status, identify diseases in the early stages and enable preventive measures.
Clinical observation of patients
This group of persons under observation includes patients with chronic diseases, convalescence patients after acute illnesses, and individuals with genetic abnormalities and congenital malformations.
The organization of dispensary observation of patients is based on the following activities:
- identification of diseases and their etiological factors;
- prevention of exacerbations, relapses and complications;
- maintaining the level of working capacity and life;
- reduction in mortality and disability.
Clinical observation after the relief of the acute stage of the disease requires measures to extend the period of remission, as well as rehabilitation measures to restore the functioning of the main organs and systems of the body.
Main goals
Clinical observation of patients has certain tasks, which are to identify people at risk, as well as patients who have a disease at an early stage of its manifestation.
Surveillance and active measures for recovery, examination of patients, their treatment and recovery from illness are shown. In addition, specialized databases are created containing information on all persons under surveillance.
What are the types of preventive examinations?
- Preliminary examination - are people who go to school or work. The main goal is to determine their ability to do the chosen thing. During the inspection, possible contraindications for the chosen profession and the presence of any pathological processes in the body are revealed.
- Periodic inspection - all persons pass in a planned manner with a certain frequency. Each request for help to a medical institution can be used by a local doctor in order to send a patient for a scheduled examination to narrow specialists.
- Targeted inspection - has certain tasks and a narrow focus. For example, during such an event, patients who suffer from one specific disease are identified.
In addition, dispensary observation can be individual and mass. An individual is carried out if a specific person turned to a doctor for help, or a home visit was made, if the patient was hospitalized for treatment or had contact with an infectious patient.
Mass inspections are carried out in educational institutions, military enlistment offices, and enterprises. These examinations, as a rule, are complex and combine periodic inspections and targeted ones.
Observation groups
After conducting an examination and assessment of a person’s condition, the latter is referred to a specific observation group:
- D1 "healthy persons" - have no complaints and deviations from the side of health;
- D2 “practically healthy” - patients with chronic diseases in the past without exacerbations, convalescents after acute development of the disease, people in borderline conditions ;
- D3 "chronic patients" - patients with reduced working capacity and frequent exacerbations of the disease, as well as people who have persistent pathological processes that have led to the development of disability.
What does the medical examination consist of?
Dispensary observation consists of several main stages. The first of these includes the registration and examination of patients, as well as the formation of groups that need further control. The average health worker keeps track of population lists, rewriting data for each patient.
The second stage consists of monitoring the health of those who need treatment and preventive measures. The first group of medical examinations is examined once a year at a predetermined time. As for the remaining patients, the therapist or family doctor should use every opportunity to send them for scheduled examinations.
The D2 group is monitored to reduce risk factors for the disease, to correct hygienic behavior. Mandatory emphasis is placed on patients who have suffered from acute illnesses in order to avoid the development of the chronic process.
For the third group of dispensary observation, the specialist draws up a plan that outlines the principles of individual treatment and wellness measures, consultations of narrow specialists, the use of medications, elements of physiotherapy, and the implementation of preventive and rehabilitation measures.
Within a year, after each examination, adjustments are made to the dispensary plan. At the end of the next year of dispensary control, an epicrisis is filled out, in which such moments are indicated:
- initial condition of the patient;
- dynamics of survey results;
- measures taken to treat, rehabilitate and prevent complications;
- final assessment of the patient’s health.
In many medical institutions , an epicrisis plan is pasted onto the patient’s card, which saves time on filling out final and intermediate documents.
The third stage of the clinical examination is based on the annual assessment of the results of the hospital, the review of positive and negative results. A review of ongoing activities is underway and certain adjustments are made for improvement.
Dispensary Controlled Diseases
Clinical observation of chronic patients is carried out in the presence of the following diseases:
- pathology of the gastrointestinal tract - peptic ulcer, chronic gastritis with reduced secretion, cirrhosis, chronic hepatitis, pancreatitis, chronic ulcerative colitis and enterocolitis;
- pathology of the respiratory system - bronchial asthma, lung abscess, bronchiectatic disease, chronic bronchitis, emphysema;
- diseases of the cardiovascular system - hypertension, coronary heart disease, heart failure;
- diseases of the urinary system - pyelonephritis, glomerulonephritis, urolithiasis;
- pathologies of the supporting apparatus - osteoporosis, osteoarthrosis, rheumatoid arthritis.
Under the supervision of a surgeon are persons suffering from varicose veins, endarteritis, phlebitis, thrombophlebitis, post-resection consequences.
If in the clinic there are narrow specialists of all areas, then the patient is not registered with his local therapist, but with a doctor who is directly involved in the clinical case.
Basic orders
Clinical supervision of all population groups is carried out on the basis of orders of the Ministry of Health.
- Order No. 1006n of December 3, 12, "Approval of the Procedure for Conducting Clinical Examination of Adult Groups"
- Order No. 87n of March 6, 2015, on the approval of the forms of documentation that is used to conduct such an event as medical observation.
- Order No. 800 dated 06/18/11 on the procedure for conducting preventive examinations of military personnel and their dispensary observation. Order issued by the Ministry of Defense.
Dispensary
In order to keep under control of people in need of medical supervision, and not to miss anything important, there is a special medical documentation.
1. Form No. 278 is drawn up at the enterprises, in educational and children's preschool institutions by the administration. Data on each person undergoing routine examinations is entered here: full name, date of examination and final results.
An outpatient medical record is considered the main document. All cards are stored in a polyclinic file cabinet. In the upper right corner, the letter "D" is marked in red. It also indicates the reason and date of registration. After deregistration, the end date is also noted here. The card records data on all examinations of the patient by specialists, examination results, treatment appointment. This allows the local therapist to assess the completeness of the examination and the general condition of the patient.
3. Epicrisis, filled at the end of each year, is done in duplicate. One is pasted into the outpatient card, and the second is transferred to the statistics department. All epicrisis is checked and signed by the head of the department.
4. Form Zh30 - a control card consisting on the "D" -account. A control card is created for convenience only. One document corresponds to one nosological form of the disease. They are placed in different drawers, depending on the month when the patient should next come for examination and examination. Every month, nurses look at a file cabinet, select patients who should be examined in the current month, and send them a call about the need to come to the clinic.
Based on the results of the examination, doctors divide all patients into the following dispensary observation groups:
- Group 1 - almost healthy;
- Group 2 - patients with chronic diseases without disability;
- Group 3 - patients with impaired ability to work in insignificant manifestations;
- Group 4 - patients with persistent disability;
- Group 5 - completely disabled people requiring constant care and treatment.
Individual plan development
At the beginning of each plan, the specialist indicates the task for a particular patient, since the load on district doctors is large: a large number of people pass through them, and the therapist is not able to remember small details regarding the level of health of a particular patient.
In the second section of the individual plan, tips and recommendations are made regarding disability and possible working conditions. If the patient has a certain disability group, then the terms of the follow-up observation and the date of re-examination are indicated.
The next paragraph includes recommendations on dietary nutrition and the duration during which the patient should adhere to it. The possible level of physical activity and activity is also indicated.
Features of therapeutic measures and prophylaxis include not only a specific indication of medications, doses and terms of their use, but also the definition of a method of therapy (in the form of physiotherapy, spa treatment). Specific dates of examination of the patient by specialists, and, if necessary, the arrival of medical workers at home, are also indicated.
Clinical examination of children
Dispensary observation of children of the first year of life is carried out en masse. The child is examined by a pediatrician every month. Its anthropometric data, general condition, and the work of vital organs and systems are evaluated. This is necessary not only to identify pathologies, but also to prevent their occurrences and determine the propensity for certain diseases.
Dispensary observation of children by a district pediatrician is indicated not only for newborns and infants, but also for patients at risk, people with chronic diseases, and children who do not attend preschool.
The role of the nurse in "D" accounting
Clinical observation of patients requires a lot of effort and time. A huge role in the clinical examination is played by nurses. The responsibilities of a nurse include:
- maintaining a medical examination file cabinet;
- sending news to patients about the need to visit a clinic or a specific specialist;
- turnout control;
- preparation of documents before the next inspection;
- fulfillment of doctor's prescriptions;
- monitoring the implementation of medical appointments by the patient;
- home patronage;
- record keeping.
The first visit to the dispensary at home is best done with a doctor. You should pay attention to the patient's living conditions and sanitary standards in the place of residence, to find out who has the opportunity to provide him with everything necessary, with whom he lives.