Outpatient patient card sample filling. Electronic medical record

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

General information

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

Medical record and its role in practice

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

Incorrectly filled cards

If medical card outpatient was filled inaccurately or was lost by the registry, then patients can present reasonable claims to the institution. By the way, in some clinics there is such a practice as intentional loss. As a rule, this happens with poor clinical outcomes, errors in prescribing drugs and procedures, etc.

One of the means 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, however, the issued electronic card has no legal force.

The outpatient medical record includes forms for operational and long-term information. Let's consider their content in more detail.

1. Operational information forms 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 return visit, for the consultation committee. Such forms are filled in as the patient contacts the doctor at home or at an outpatient appointment, and are glued to the spine of the card.
2. Forms of long-term information contain signal marks, information about preventive examinations, sheets for recording already specified diagnoses and sheets for prescribing any narcotic drugs. These inserts are usually attached to the cover of the card.

Basic principles of card management

An outpatient card is required for:

• description of the patient's condition, outcomes of therapy, treatment and diagnostic measures and other information;
• adherence to the chronology of events that influence the adoption of organizational and clinical decisions;
• reflections of physical, social, physiological and other factors influencing the patient during the entire pathological process;
• understanding and compliance by the attending doctor with all the legal nuances of their activities, as well as the significance of medical documentation;
• recommendations to the patient after completion of the examination and completion of treatment.

Card issuance requirements

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

Each entry is signed only by the attending doctor with a transcript of his full name. Recordings that have nothing to do with the care of 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 the provision of emergency care.

Project

STANDARD OF MANAGEMENT
OUTPATIENT CARDS OF THE PSYCHIATRIC ROOM​

Introduction.
Of course, the main thing in the design and maintenance of an outpatient card (in order of priority) are:

First of all, it is literacy medical records, statements of the patient's complaints, the completeness of the history taking, the quality and professionalism of the description of the mental status, the diagnosis of its justification.

Secondly, the adequacy of the medical recommendations made and the chosen medical tactics.

Thirdly, further compliance with the required frequency of observation of the patient by a psychiatrist and a nurse in a psychiatric office in accordance with the approved dispensary observation groups.

Finally, this is the quality of the design of the outpatient cards themselves.

It is also undoubtedly important that the entries in the outpatient cards and the "Control cards for dispensary observation of the mentally ill" (f. 030-1 / y)

However, nevertheless, we consider it expedient to start with the issuance of outpatient cards, with their general appearance, title page, insert sheets, layout of documents (extracts from medical records - exchange cards, requests, etc.).

1. Registration of outpatient cards themselves.
1. Design of the title page (1st page).

- No mark (stamp of the institution) in the left upper corner on the belonging of the outpatient card to the institution.
- Only the year of birth of the patient is indicated, not full date birth, as required.
- The district or city where the patient lives is not indicated.
- The affiliation to one or another observation category is not indicated in the upper right corner: "Dispensary group" or "Advisory group". Here (in the upper right corner) a square with the letter "D" (Dispensary group) or "K" (Advisory group) should be pasted. As the category of observation of the patient changes, this marking changes.

2. Registration of the "Koreshka" outpatient card. Marking.

3. Registration of the 2nd page - "Sheet of the final (refined) diagnosis".

Common bugs and defects:
Sometimes the page is not filled out or a diagnosis is made at the syndromic level.

2. Literacy of registration of medical records.

First recording doctor in the outpatient card when receiving a patient should be the most detailed and complete.

1. At the beginning it is indicated where the consultation took place(examination, examination, examination) of the patient.
As a rule, these are the following options: "At the reception" or "At home". "At the reception" - means in the premises of the dispensary (dispensary department or in the psychiatric office of the Central District Hospital, or polyclinic), i.e. at the place of the main reception.

Other places are also possible, these can be: "In the hospital or the Central District Hospital", "During the visit to the FAP or to the district hospital", "In the school premises", "At the meeting of the IPC", "In the premises of the Commission on Juvenile Affairs", "In the boarding house" or "In the boarding school", "In the investigator's office", "In the premises of the police department" or, respectively, other options. The date is also entered here, and individual cases and, if necessary, the time of the inspection.

2. Then marked circumstances of the appeal.
These can be: "Self-appeal", or "As directed by a neurologist", or "As directed by a general practitioner", or another doctor, or "As directed by a FAP paramedic", or other responsible persons. Thus, here, in fact, the initiator of the contact is indicated patient and psychiatrist, from whom specifically the initiative came.

The next required note is how or with whom the patient arrived at the appointment: "Alone" or accompanied other persons. For minors - "with the mother", "with the parents", "with the school teacher", "with the director of the school", "with the juvenile affairs inspector". If the examination (consultation) of the patient took place outside the psychiatric office, then it is necessary to indicate in whose presence the examination took place.

Goal of request . Requests. For help. For a prescription.

Legal aspect. Voluntary examination during the initial treatment.

3.Complaints.

4.Anamnestic information. VIEW MORE
- Completeness of the history taking, availability of the necessary characteristics, information from the words of relatives, certified by their signature, extracts from the case histories of other medical institutions and / or outpatient cards, filing of previous case histories of psychiatric hospitals (in case of loss of previous case histories, an official answer about this is filed from archive);
- Timeliness of execution and conduct of fluorographic examinations, the correctness of the relevant records, the presence of 2 readings of the conclusion in the form of ciphers and the cipher of a medical worker;
- Availability of examinations and results on diphtheria (2-digit result, "freshness" of the analysis (no later than 10 days before hospitalization);
- Availability of examinations for HIV infection in accordance with the current indications and orders;
- Completeness of other paraclinical studies (blood, urine, ECG, EEG, ECHO-Encephalography, CTG, NMR, etc.);
- Presence according to indications of examinations of a neuropathologist, a medical psychologist.

2.5. Mental state.
The quality of the description of the mental status of the patient. Description of the noted manifestations, symptoms mental disorder and their interpretation;

2.6. Diagnosis, leading syndrome.
a). Correspondence of the established diagnosis with the data of the anamnesis, patient complaints, mental status.
b). The correctness of the detailed clinical diagnosis.
V). The correctness of the coding of the diagnosis.

3. Adequacy of medical recommendations.
3.1.Recommendations for treatment.
- The adequacy of the prescribed treatment to the age, physical, somatic, neurological and mental state of the patient, his health complaints, the characteristics of the course of the disease;
- The dynamism of treatment in accordance with the change in the mental state of the patient, somatic burden.

Note No. 1: The adequacy and dynamism of treatment is assessed based on the size of the dose of drugs, the timeliness of increasing or reducing the dose, the time of prescribing the drug during the day, and the correct selection of the complex of drugs.

3.3. Note on the appointment of the next visit to the doctor (recommended next consultation).

3.4. Signature of the doctor (indicating next in brackets legibly his last name and initials or affixing the personal seal of the doctor).

Common bugs and defects:
...

4. Assessment of compliance with the frequency of observation.

In a psychiatric office, the dispensary observation system should be clearly defined from those recommended by the Ministry of Health of the USSR or the Ministry of Health of the Russian Federation and accepted for use in practical work on the territory of the region ("according to V.G. Zenevich", or I.Ya. Gurovich, or others).

Common bugs and defects:
...

5. Correspondence of records in outpatient cards and "Control cards for dispensary observation of the mentally ill".

Common bugs and defects:
...

METHODOLOGY
EXPERT ASSESSMENT OF OUTPATIENT CARDS
PSYCHIATRIC ROOM​

Expert evaluation of outpatient cards (hereinafter referred to as "Assessment") of a psychiatric office of a dispensary, dispensary department psychiatric hospital or CRH is carried out on site during a supervisory review.

The assessment is given based on the results of the curator's study of approximately 30-50 outpatient cards (f. 025-y). When evaluating outpatient cards of patients from the dispensary group, they are compared with the "Control cards for dispensary observation of the mentally ill" (f. 030-1 / y).

The assessment is carried out in 5 main sections:
1. Literacy of registration of medical records.
2. Adequacy of medical recommendations.
3. Compliance with the required frequency of observation of the patient.
4. The quality of the design of the outpatient cards themselves.
5. Correspondence of entries in outpatient cards and "Control cards for dispensary observation of the mentally ill" (f. 030-1 / y).

The full version of the document is attached to the message.

Proper filling of the outpatient card of the patient has great importance for doctors, since it is in it that all information about a person’s disease is stored. Also, the card becomes evidence in court proceedings, if any. With the help of this document, a medical examination, verification of the work of specialists is carried out. For insured people, the medical card will be a confirmation of the insured event.

The current form of the card

In 2015, the Russian Ministry of Health issued a new order (“On Approval unified forms medical records used on an outpatient basis and the procedure for filling them out”), according to which all medical records and the rules for filling them out have been updated. This order is of great importance, as it allowed medical institutions to carry out continuity among themselves.

The new outpatient card has undergone major changes. It contains more detailed information about a sick person, since it contains the specifics of paragraphs and subparagraphs. They must be filled out without fail. Prior to 2014, patient records were less extensively maintained by different physicians. The order obliges to record information about the consultation of doctors, managers. It is obligatory to record the meeting of the commission of medical specialists. Specialists in a medical institution are required to keep records of patient exposure to x-rays. If a sick person needs to seek help in any specialized unit, then another form of the patient's outpatient card is filled out there.

Filling rules

During the very first visit to a medical institution, an employee at the reception fills out the title page of the issued card. The title page contains detailed information about the patient. Entries in the outpatient medical record itself will be completed directly by medical professionals. Employees of the institution, who have a secondary medical education, are engaged in entering information into the register of patients who receive assistance.

The title page of the document indicates the serial number of the sick person's card. If he has the right to a number of social services, then the letter “L” is indicated next to the number. During the appointment, the doctor must indicate the date of the visit. Also, the record should reflect the nature of the disease, various diagnostic and treatment measures that are carried out by specialists. During the description of the disease, it is necessary to indicate the cause of its occurrence. For example, poisoning, accident, etc. All entries must be in chronological order. The doctor is obliged to make entries in the card for each visit of the patient. Registration on the territory of the Russian Federation must be carried out in Russian (neatly and without any abbreviations). However, the names of drugs can be written in Latin. If the doctor made a mistake, then it must be corrected immediately, and then certify this place in the text with a seal and signature. Each doctor has his own nominal seal, through which such actions are carried out. An example of an outpatient card is presented below.

Some maps are thicker, some are thinner. It all depends on the number of illnesses and visits to specialists. The completeness of descriptions of the picture of the disease and symptoms will help to make the most correct diagnosis for a sick person. Sometimes a consultation of several doctors of various specializations is necessary to make a diagnosis. In the vast majority of cases, information about human analyzes is needed. All these data must be displayed in the medical record. Based on the conclusion of narrow specialists, the therapist will be able to make the correct diagnosis. It often happens that the symptoms and pain in a person can be related to several types of diseases at once. Therefore, it is necessary to exclude all ailments that a particular patient does not have.

Filling out the title page

The title page of the outpatient card Form 025/U must be completed in detail. To fill out, a person must present a passport to an employee if he is a citizen of Russia. If he is a sailor, then a sailor's certificate will do. Employees in the army must present a certificate of a serviceman of the Russian Federation. If a foreign citizen applied to the polyclinic, then he has the right to present his passport or other identification document and specified in the International Treaty. To visit a medical institution, a refugee must use an application, as well as a refugee certificate. Stateless persons can apply to the polyclinic. For them binding document is a temporary residence permit.

The position and place of work of the patient are indicated without fail, but according to the person (certificates from work are not required). Also, the staff of the registry during the issuance of an outpatient card additionally request TIN and SNILS. Filling out the title page is not a difficult procedure, since small print hints about the information in each column are registered. To visit the local attending physician, a person must provide information about the place of residence. Depending on the address, the patient is recorded to a specific doctor, as the territory is divided into streets. Sometimes a person goes to the clinic at the place of residence, and not at the place of registration. Such actions are not prohibited by law. A person can be registered in one city and live in another.

Electronic card

The electronic outpatient card has not yet been fixed at the legislative level, but has already begun to function. The pilot project is currently underway. An electronic map will be useful, as it will allow you to store information on digital media. It will also help the coordinated work of various medical institutions, for example, a clinic and a hospital. Also, the electronic card will become an opportunity for the exchange of experience between specialists in the same direction.

This service will be designed to store all information. Access can only be granted to persons authorized in this program. Also, an electronic medical record of an outpatient will contain all the information from various medical institutions where this person applied. In order for all information about the patient's visit to the polyclinic to be stored in the system, it must be correctly entered and recorded.

The electronic card will contain the following information about the patient:

• Anamnesis.
• Days of visits to the clinic.
• Diseases.
• Surgical interventions.
• Referrals to other medical institutions for diagnosis, treatment, and so on. Their data.
• Vaccination.
• Diseases that are of social importance.
• Disability, the reason for its occurrence.

Since this information is personal, protection from unauthorized interference is necessary. For this, the employee's electronic signature is used.

Persons using the program:

• Medical institutions, doctors, specialists. Employees of medical institutions who use the program are required to comply with medical secrecy. They are also involved in entering information into an electronic map.
• Patients. They only have access to their medical records.
• Other persons who may be provided with non-personalized information for statistics, analysis, and for further planning of actions in the field of health.

The quality of filling the card

The law of the Ministry of Health of the Russian Federation does not prescribe the specific content of the records of specialists in the outpatient card, but all of them must have a certain sequence, be deliberate and logical. In order to avoid comments from the regulatory authorities, it is necessary to describe in detail all the patient's complaints. It is necessary to indicate how many days have passed since the onset of pain and discomfort until the first visit to the doctor. The doctor is obliged to characterize the disease, indicate the state of the person at the time of the visit. The diagnosis must be indicated in accordance with the international classification of all diseases. It is also important to describe the comorbidities that the patient suffers from.

The specialist's record should include a list of medicines for treating a sick person, referrals to other specialists, examination results, information on providing sick leave, various certificates, as well as information about the availability of benefits for the patient.

In the same way, in the outpatient chart, the specialist must fill out correctly each visit of the patient. Also, the card must contain a signature on the person's permission for medical intervention or his refusal.

During the return visit of a person, the doctor must carry out the description in the same order. But it is also important to focus on the changes that have occurred since the first visit of a sick person. In the patient's outpatient card, you need to enter data on epicrises, consultations, and conclusions of specialists. If a sick person dies, then the specialist must issue a post-mortem epicrisis. All information about previous illnesses, surgical intervention is entered into it, and the cause of death is set. After that, a death certificate is issued to relatives this person. There are situations when it is difficult to determine the cause of death. The data from the map can help specialists figure it out.

Access to medical records

The information contained in the patient's outpatient record is a medical secret. It is prohibited by law to disclose it, even if the person has died. The fact of a person's treatment to a medical specialist is also not disclosed. The law allows certain individuals to provide patient information without their knowledge. It is legal in such cases:

• The patient is underage or unable to express his will.
• A detected infectious disease can cause an epidemic or lead to infection of people who have been in contact with the patient (for example, when venereal diseases are detected, everyone who has had sexual intercourse with the patient is mandatory checked).
• A patient's illness can affect the course of a criminal investigation.

However, lawyers, lawyers, employers, notaries do not have the right to receive information from the card without the permission of the patient himself.

Patient rights

Patients and their legal representatives have the right to receive information from the card. Based on the data obtained, they can also receive advice from other specialists. The patient also has the right to receive copies of medical information, but only after a written application. Employees of medical institutions do not have the right to refuse to provide this information, as there are no grounds for this. The application does not require the patient to describe the reason or purpose in order to receive an outpatient card discharge. There should be no charge for photocopying information. The employee must register in the journal the presence of an application for reporting. On this moment the law did not provide for the issuance of the original outpatient card.

If for some reason a sick person cannot independently obtain a copy of the card, then he can write a power of attorney to another person. If employees refuse to provide information to the client, then these actions may entail administrative or criminal liability. There is also criminal liability for providing incomplete or false information patient.

Peculiarities

Many patients are dissatisfied new form outpatient card and established rules. They wonder why they can't get the original of their own card. The Ministry of Health clarifies that the outpatient card is only for medical professionals and their colleagues, so that the treatment is carried out professionally. The order in the database depends on its location in the place intended for it. If the patient needs information, the employee can always provide a copy of the data. A medical institution issues an outpatient card to a person when he moves and leaves the clinic. In other situations, the card must remain in the medical institution, as it is the property of the clinic.

Statements

Every person has a medical card, as it is entered in the name of the baby immediately after his birth. Sometimes a person needs an extract from an outpatient card. This document is called "help 027/U". Often this certificate is requested in kindergartens, when a child enters school, as well as at the workplace. At work, this document may be requested to make sure that the person was really sick at some period of time.

The receipt of the document is fast. You need to seek help from a general practitioner or pediatrician in your area. Based on the information contained in the medical record, a certificate will be issued. For it to become valid, it is necessary to put several seals. The difficulty in obtaining an extract from an outpatient card can only be in the presence of many diseases, since often the doctor must describe them all.

Sometimes it takes a couple of days to get help. This may be due to the absence of specialists at the workplace who certify the extract. The seals are put not by the attending physician, but by another employee. However, in many polyclinics, a special employee is allocated for this or this procedure is entrusted to the registry staff. They are always present at their workplace, so there are no problems with the assurance of an extract. A sample extract from the outpatient card is presented below.

Conclusion

The medical card is a mandatory document for all people who applied to the clinic for medical care. The outpatient card form is entered at the registry office. To apply, a person must submit Required documents. The information contained in the medical record is a medical secret. Patients cannot receive the original card. If necessary, the employee can make a photocopy of all data or issue an extract. Employees who provide false or incomplete information will face administrative or criminal liability. Lawyers, advocates and notaries, without the consent of the patient himself, are not entitled to receive information from the outpatient card.

An electronic medical record has begun its operation, which will help to systematize and combine all information about the diseases and treatment of each patient.

In the near future, an electronic medical record of an outpatient can significantly facilitate the work of polyclinic staff. Paper maps will be phased out gradually.

What is a medical card of this format?

EHR is a promising direction in the development of outpatient medical care. The abundance of paper cards with their significant shortcomings makes not only patients suffer, but also all employees of polyclinics. The EHR has been designed to be more user-friendly and to make it easier professional activity second. In addition, it allows you to significantly simplify the activities of the organizational, methodological and statistical departments of any medical institution.

Most importantly, you can include exactly the same information in an electronic medical record as in its paper counterpart.

The principle of operation of the EMC

IN Lately all institutions of the medical and preventive sphere are striving for maximum computerization. For the same purpose, an easy-to-use EHR has been developed, the use of which greatly simplifies the work of the staff of medical institutions and the lives of patients.

EMC is quite simple. It is contained in an electronic filing cabinet, which is part of a special program for automating the workplace of a certain medical specialist. To access a particular card, the doctor or nurse simply needs to type the patient's name in the appropriate search bar. If the program contains several records about patients with the same data, then the doctor is guided by the year of birth or address of residence of the person. If the card has already been filled out, then it will contain a fairly large amount of information that relates to a particular patient. In addition, the card allows the medical worker to track the dynamics of the patient's visit to any specialist. Of course, this information carrier allows you to easily get acquainted with every diagnosis that has ever been made to the patient. Now, in the age of computers, this is very important.

It should be noted that a modern EHR of an outpatient would not carry great sense, if it were not included in a specialized program that unites the computers of all specialists who work in medical institutions. That is, other specialists, for example, a gynecologist or a therapist, including those working in another clinic, have the opportunity to familiarize themselves with the diary filled out by a surgeon. The data is provided in real time. Thus, the program is a single medical base.

What is an electronic health record for?

The purpose of creating an EMC

EMC became necessary due to general computerization modern society. It should be noted that the idea of ​​creating such a system arose quite a long time ago. Specialists have long been tired of working with a large volume of paper documents that have a huge number of shortcomings. In addition, a unified EMR greatly simplifies the activities of medical hospitals, which have been able to request information regarding a patient entering treatment in a digital format. Such an opportunity greatly simplifies the activity - doctors do not have to find out what their patient was ill with throughout his life. Why is an electronic health record so good?

Advantages of an EMR over a paper card

It is worth noting that EMC really has a huge number of advantages. Firstly, such a card will never be lost, the patient will not be able to take it home. Thus, the information is always located directly in the clinic.

The next advantage of an electronic card is that there is no need to search for it, then transfer it to a certain specialist by the registry. All data is always available to the doctor on the computer.

Another undoubted advantage of the EHR is that there is no need to constantly paste additional sheets, advisory opinions, research and analysis results into it. All such information is entered into certain columns of the program, which provides the necessary information at the first request of the doctor.

Several polyclinic specialists can familiarize themselves with the contents of the electronic card of an inpatient patient at the same time. In this case, it is possible not only to simultaneously read the map, but also to fill it. This feature allows you to significantly optimize the activities of the staff of a medical institution.

Disadvantages of EMC

Like any other modern invention, the electronic card has not only advantages, but also, unfortunately, disadvantages. The most significant disadvantage is that in the event of a possible power outage, the card becomes completely inaccessible. Such a negative feature can significantly affect the treatment of the patient in emergency situations.

The next disadvantage to be noted is the possibility of valuable information being stolen by computer scammers. In addition, the electronic record of an inpatient may be partially or completely destroyed if the main computer that stores the main database is damaged.

Another noticeable drawback of this type of documentation is that it requires mandatory training of personnel to properly work with the program. Of course, young nurses and doctors learn quite quickly, sometimes even without outside help. But older employees often experience significant difficulties in mastering a variety of innovations, especially those related to working with computer technology.

Problems arising from the universal introduction of an electronic health record

In addition to the problem of staff training, there are some other difficulties. First of all, we are talking about the need to equip the workplaces of all doctors and most of the nurses with computers. To this end, the management of the medical institution has to spend significant amounts Money. However, this problem gradually resolved, albeit not as quickly as we would like.

A much bigger problem is the transfer of all the necessary information from paper media to the information base after it becomes mandatory for use. People are used to having a medical card in their hands. It is still not entirely clear who will carry out such a large amount of work. Quite often, the doctor does not even have time to fill out an electronic card, not to mention digitizing the existing data. If we consider the staff of the registry and nurses, then they do not have the appropriate knowledge to fully transfer specific data. It would also be true to assume that no one will hire additional employees.

Probably, this problem will be solved in the following way: during the first few years after the mandatory introduction of the medical record form, both electronic and paper records will be maintained in parallel. However, this approach can bring a lot of inconvenience to doctors and nurses. Thus, before the creation and introduction of EHR, it is necessary to find an effective solution to this problem.

Development outlook for EMC

An electronic card is created for the purpose of subsequent full optimization of the activities of medical institutions. It is assumed that in the future the system will be seriously developed and there will be no need for a regular registry. It will be replaced by electronic registration.

This will free up significant labor resources and increase the number of pre-medical offices. It is worth noting that the benefits of their implementation have already been felt not only by patients and medical workers, but also by the administration.

There is some more promising direction, involving the development of an electronic medical record. The creation of a universal unified EHR will allow obtaining data from specialists working not only in one medical institution, but also in all treatment centers in the country. In the future, it is planned to create a common database that will unite all medical institutions in the country into a network. The result will be that patient data will never be lost, and a medical specialist who sees a person for the first time at his appointment and is several thousand kilometers from the attending physician will be able to obtain complete information about the patient's history in just a few minutes. Such a system, in addition, makes it possible to exclude various frauds with certain medical documents.

Electronic registration can be very convenient.

Protection against equipment failure

In fact, the most serious problem is the probability of equipment failure, that is, the computer on which the single base data containing a complete electronic file of a particular medical institution. A fairly good solution is to periodically back up the shared database and then place the copies on separate computers. Thus, if one computer breaks down and cannot be restored, another machine can be started, storing a copy. Such a technique will avoid serious difficulties in the work of medical personnel with an electronic file.

Another suitable solution is to host database backups in cloud storages. However, this technique has a significant drawback - it will be easier for various Internet scammers to access the information located in the online storage.

What is the benefit for the patient?

The creation of an electronic medical record of a patient implies a significant benefit for him. Firstly, each patient can be sure that not a single conclusion or research result will be lost from his medical record. In addition, when visiting a medical institution, the patient will not have to stand in line waiting for the receptionist to find his card and give it to the doctor. Everything will be much easier in the near future. The patient only needs to make an appointment with a specialist. When visiting a polyclinic, it remains to present a health insurance card, and then you can immediately go to the doctor whose consultation he needs.

What else is interesting about a personal electronic medical record of a patient?

The next benefit that the patient receives is confidentiality. Information about the doctor's appointment, the diagnosis made and the results of medical examinations will become inaccessible to representatives of the junior medical staff. The problem is that when modern system accounting and data storage medical records, as a rule, are located in the registry. Employees working there have full access to the maps and can look at absolutely any map not only of their own interest, but also at someone's request. New system storage of medical data of the patient will completely exclude such a possibility.

Deadlines for the implementation of the project for the implementation of the EHR system

In fact, the full introduction of electronic medical records of the patient and the cessation of paper records in clinics was a foregone conclusion at the stage of creating this system. Unfortunately, such a promising project has been in development for a long time due to the fact that various obstacles constantly arise.

At the very beginning, a significant problem was the impossibility of fully equipping clinics with appropriate technical means. Then there was the need for staff training. At the moment, this problem is practically solved, however, there is a need to ensure the program works without failures. It is expected that this obstacle will be removed in the near future. That is, the most significant problem is the digitization of existing paper forms from the archive of medical records.

economic benefit

Despite the fact that the initial stages of the introduction of an electronic card system involve significant implementation costs, in the future such a system will save much more money. The fact is that every year every medical institution spends huge amounts of money on the purchase of a variety of paper products. Of course, the introduction of an electronic card system will require high energy costs, but the overall savings will still be significant.

Introduction of a single regulation for maintaining electronic patient records

At the moment, the developers of the aforementioned system are striving to implement certain measures for the full systematization of activities in the field of computerization of various medical centers, medical institutions and clinics. The catch is that at the moment, not one version of the electronic medical record of an outpatient has been developed, but several. And there are also several possible unified storage systems.

Such options were in the work of not only representatives of medical institutions and universities, but also private organizations. By order of the Ministry of Health, a special program was created to automate the workplace of doctors of various profiles.

The result was that this system is recommended for implementation in various medical institutions. The need for this lies in the further possibility of integrating most medical institutions into one single network. Thus, in the near future, maintaining an electronic medical record will allow absolutely every specialist to get access to information about a patient who has come to see him in a matter of minutes.

Despite the existing shortcomings and obstacles to the introduction of the EHR system, developers are striving for effective problem solving and the fastest possible transition from paper to electronic charts.

According to the Ministry of Health, in the near future all patients will be able to use virtual personal account, and doctors will be able to enter a medical history in an electronic medical record. Thanks to this new direction in the development of outpatient care, both parties will have more free time, by freeing them from unnecessary paperwork. In addition, an electronic medical record greatly simplifies the maintenance of statistics, because as a result it will greatly facilitate and optimize labor activity hospital staff. The treatment process will become easier and faster.

How does an electronic patient record work?

To date, almost all medical institutions are equipped with computers with appropriate software. Many hospitals and clinics work with RoboMed software, which offers convenient and fast entry, prompt processing and secure storage of all information.

One of the components of this provision is an electronic medical record. Its interface is quite simple and convenient. In order to access information about a particular patient, a specialist only needs to type his full name in the search bar. If the program simultaneously issues several people with identical personal data, the doctor will be able to navigate by the patient's date of birth or address.

Also in the electronic medical record, if it is completely filled out, a large amount of information relating to a particular patient is stored. Thanks to it, you can easily and quickly view the dynamics of visits to a particular doctor. All previously diagnosed diagnoses, information on drug tolerance and other important data are recorded here.

Since the electronic medical record is part of the RoboMed software, all specialists working in a particular medical institution have access to it. That is, for example, the surgeon, to whom the patient turned, can study the conclusions that were written by other doctors involved in the treatment of this patient. This outpatient card keeps records of an internist, gynecologist, orthopedist or any other specialist. You can get acquainted with them in real time.

Advantages

For those who use the RoboMed software, and in particular the patient's virtual medical document, the advantages of this innovation become apparent. The advantages that an electronic patient record has over its paper counterpart can be seen already at the first use. The fact is that almost all employees of a medical institution are well aware of how long and tedious the process of finding the necessary copy in the file cabinet can be. In addition, there are cases when it does not lead to the desired result. That is, the necessary card of a particular patient is not in place.

When using the electronic version, such problems will not arise. Another disadvantage of traditional maps is the fact that they are not always able to be supplemented in a timely manner with information about the medical procedures performed and the results of the analyzes. Sometimes this situation can significantly complicate the process of interaction with patients.

In addition, it often happens that the medical record or test results are lost. Thanks to the creation of an electronic outpatient card, both the patient and the doctor do not have to worry about this, since all data is fully stored on cloud servers. You can make entries in the medical card throughout a person's life. This is very important, since the patient himself may forget or not know, for example, that he has an allergic reaction to any medicine. The outpatient's electronic health record will retain all this information, unlike the paper version, which can become frayed or lost over time.

Prospects for the development of electronic cards

All entries in the electronic outpatient card are strictly grouped by topic. Each specialist will be able to easily understand the information recorded earlier by another doctor. To do this, just open the necessary tab. Electronic medical records of patients include the following sections:

• initial inspection;
• patient complaints;
• examination of specialized specialists;
• hardware and laboratory examinations;
• preliminary diagnosis, etc.

The likelihood of widespread use of electronic outpatient records increases every day, since this medical document has a number of possibilities. For example, a specialist can:

• print the information of interest to him;
• forward by e-mail a card to another medical institution or specialist;
• put an electronic signature.

It is also possible to delete the card with the possibility of its further restoration. At the same time, the statute of limitations for moving a document to the repository does not have strict restrictions. Thanks to all the above advantages, experts argue that the electronic medical record of an outpatient will soon completely replace paper analogues from circulation.

What is the benefit for the patient?

The advantages of an electronic outpatient card are obvious not only to the doctor, but also to the patient. The patient feels how much faster and easier the treatment process has become. There is no more need to waste time standing in lines at the reception in order to get your medical history. Now all information about a particular patient is in the cloud storage of a medical institution.

In addition to the clear benefits for patients, the clinic and its staff also benefit greatly from the acquisition of this state-of-the-art IT system. So, for example, thanks to the use of RoboMed software, the effectiveness of treatment becomes higher due to the standardization and control of each action of the staff. This system has the following advantages:

• Growth of profitability of a medical institution by 4-6%. This effect is achieved by detecting the inefficiency of personnel actions, optimizing work processes and increasing the average check.
• The expansion of the customer base. This process occurs due to the improvement of the quality of treatment and the level of patient satisfaction. A client of a medical institution with great desire and loyalty seeks further help.
• The level of dependence on staff turnover is reduced. This is due to a decrease in the period of adaptation of new specialists. Thanks to the operation of the RoboMed software, all errors that employees make will be displayed in the system in real time. As a result, they can be fixed and eliminated in time.

It is worth saying that the software was created on the basis of domestic and international experience. This IT system has been successfully tested in many Russian clinics. In the course of its use, it has repeatedly confirmed its effectiveness and stability in real conditions. Therefore, the RoboMed system is already used by many medical institutions in our country.