Sample of a child's medical card. Patient's outpatient record. Introduction of the updated form

Every person has probably been to a medical institution, where one of the most important documents is the medical record of an outpatient. Neither the doctor nor the patient can do without it.

Why is an outpatient card necessary?

How correctly this document is filled out may determine the fate of the patient in the framework of a possible criminal or civil case being investigated in relation to him.

An extract from the outpatient card is required:
⦁ when carrying out forensic medical examinations;
⦁ to make payments for the provision of medical care under compulsory medical insurance contracts;
⦁ to conduct medical and economic examinations to monitor the quality of medical services provided.

What is a patient's outpatient card?

In Federal Law No. 323, approved in November 2011, regulating the health protection of our compatriots, there is no such thing as medical documentation.

The medical encyclopedia includes a system of documents that have a prescribed form, the purpose of which is to register information about measures for prevention, treatment, diagnosis and sanitary hygiene.

Medical documentation can be accounting, reporting and accounting. The outpatient medical record falls into the first category. It describes the diagnoses, the current condition of the patient, and recommendations for treatment.

Introduction of the updated form

Order of the Russian Ministry of Health No. 834 of December 2014 approved updated unified forms of documentation used by outpatient medical institutions. It also states how they are filled out.

This is a significant step towards the creation of an electronic medical record, since the introduction of uniform standards in the execution of records ensures mutual continuity among medical institutions.

In particular, form No. 025/u - “Medical record of an outpatient patient” has been developed, and it is described in detail how it should be filled out. In addition, a sample patient coupon with the appropriate filling procedure has been approved.

The above-mentioned order gave this card the status of the main registration medical document of an institution providing medical care for the adult population using outpatient conditions.

How is it different from the old form?

In the new accounting form, the information content has been significantly increased, and the positions to be filled out have been specified in more detail. In the previous version, the doctor could make notes at his own discretion; now they are unified.

The following information was required to be entered:
⦁ about consultations with narrow medical specialists and the head of the department;
⦁ about the result of the meeting of the All-Conference Committee;
⦁ about taking x-rays;
⦁ on making a diagnosis according to the 10th International Qualification of Diseases.

For each specialized medical institution or their specialized structural area in dentistry, oncology, dermatology, psychology, orthodontics, psychiatry and narcology, its own outpatient card has been developed. Form No. 043-1/u, for example, is filled out for orthodontic patients, No. 030/u is intended for a control card for dispensary observation.

Form No. 030-1/u-02 is issued for persons suffering from psychiatric diseases and drug addiction. It was approved in Order of the Ministry of Health of the Russian Federation of 2002 No. 420.

How is it filled out?

During a person’s very first visit to the clinic, the receptionist fills out the data on the title page. But a patient’s outpatient card can only be filled out by doctors.

If the patient belongs to the category of federal beneficiaries, an “L” is indicated next to the card number. The doctor must make an appropriate record of each patient’s visit to the clinic.

The outpatient card reflects:
⦁ how the disease progresses;
⦁ what diagnostic and therapeutic measures are consistently carried out by the attending physician.

The entry is made carefully, in Russian, in the appropriate section without any abbreviations. If it is necessary to correct something, this is done immediately after the mistake is made and must be certified by a doctor’s signature.
It is acceptable to use Latin to write the names of medications.

The health worker fills out the first sheet in the registry according to the data from the patient’s identification documents. Workplace and position graphs are recorded according to the patient’s words. The form contains recommendations for completing each section.

Filling principles

When filling out an outpatient card, you should remember some basic principles.

It should describe in chronological order:
⦁ in what condition the patient came to see the doctor;
⦁ what diagnostic and therapeutic procedures were performed;
⦁ treatment results;
⦁ circumstances of a physical, social and other nature that influence the patient during pathological changes in his well-being;
⦁ the nature of the recommendations given to the patient at the end of the examination and treatment process.

The doctor must comply with all legal aspects when filling out the form.

The outpatient card consists of forms on which long-term and operational information is recorded.

Long-term information contained on front-adhesive sheets includes:
⦁ information copied from an identity document;
⦁ blood group with Rh factor;
⦁ information about previous infectious diseases and allergic reactions;
⦁ final diagnoses;
⦁ results of preventive examinations;
⦁ list of prescribed narcotic drugs.

Operational information is recorded on inserts where the results of the initial visit and secondary visits to the local therapist, specialized doctors, and consultations with the head of the department are recorded.

Extract from outpatient card

An extract is a medical certificate of health in form 027/y, which belongs to the second group of medical records documentation. It contains information about illnesses suffered during outpatient treatment.

Its purpose, like all the documentation of this group, is to quickly exchange data on the health of patients, which helps to connect the individual stages of sanitary-preventive and therapeutic measures.

The extract can be provided by the patient to the employer to inform about the completion of outpatient treatment. It is not subject to payment, but is submitted together with the sick leave certificate, if the latter is issued for more than a month.

This document allows you to be exempt from classes in educational institutions.

The extract contains information about the patient, indicating the medical policy number, listing his complaints, symptoms of the disease, the results of medical examinations and examinations, as well as the primary diagnosis.

All information must fully correspond to that contained in the outpatient card.

The extract can be used to prescribe further medical procedures.

A child’s medical card is created for each child attending school or kindergarten. The form of the child's medical record is usually standard. Let's look at what the sections of this map consist of.

Child's medical record 026

A child’s medical card is used in educational institutions; it is issued for each minor child studying in kindergartens, general education and other schools, and similar organizations.

You can maintain medical records of small patients online using the Clinic Online service. Try it and see how convenient it is.

Get demo access to the Online Clinic

The child’s medical record 026 U contains detailed data on the degree of moral and physical development of the child, whether he has any health problems, and so on. The form of a standard medical card for a student (pupil) also allows you to record information about the assignment of a minor to a certain disability group by type of health, etc.

A child’s medical record is usually filled out by a kindergarten or school health worker, or by doctors, nurses or clinic paramedics.

You can download a sample child's medical record below.

Structure of the child’s medical record form

The medical record is divided into several parts, in which various data about the minor are entered:

• General information about the student (pupil)
• Medical history information for minors
• Data on whether the student (pupil) is registered with a dispensary.
• Information about the timing and actual completion of mandatory medical procedures
• Information about the timing and actual completion of immunization
• Data on the timing and actual completion of medical examinations required by the minor’s age
• Results of consultations with medical specialists
• Recommendations for attending classes and their nature in various sports and other sections
• Data on how boys are trained for military service
• Current results of tests and medical observations of the student (pupil)
• Test data and medical reports.

How to fill out a child's medical record form

According to the regulations, the child’s medical record form must be filled out by a health care worker in accordance with the requirements for its registration.

What is written in the “General Information” section

1. General information about the child.

1.1. Last name, first name, patronymic of the child ____________ 1.2. Date of Birth___________

1.3. Gender (M/F) 1.4. House. address (or address of a boarding school)__________________

1.5. tel. m/residential _____________ 1.6. Servicing clinic______________________________ 1.7. tel___________________

The “General Information” section contains all information about the student (pupil), as well as about the medical institution to which he belongs, taking into account his place of residence. The section includes the following information:

• details of the minor's name and address;
• information about the clinic where he is served;
• information about which school or kindergarten he attends.
• information about transfer to any other educational institution, if any;
• in a special column all those negative conditions in which the minor is forced to be daily for some reason are reported.

The child's medical record 026 U also reports whether the minor has any allergic reaction, indicating the reasons for the allergy.

Contents of the section “Anamnestic information”

Information about the medical history of minors is the next section of the medical record 026 U. It contains general data and characteristics of the family of a school student or kindergarten student. In addition, it contains information about the child’s living conditions and describes the illnesses that he suffered. Externally, the section looks like this:

The most significant points in this section of the child’s medical record:

• Information about the student’s family
• This section includes information about the composition of the minor’s family and the general situation in it.
• Information about whether the student (pupil) and his family members have chronic or hereditary diseases
• A special section of the section includes additional information about whether the student (pupil) participates in sections or interest groups that the student (pupil) attends.
• Data about illnesses suffered by the student (pupil), about various injuries, or about the operations that the student (pupil) underwent; this also includes information about being in a children's sanatorium-resort complex.

The medical worker of the school or boarding school provides information about all this based on the data of a regular medical outpatient card, and based on the results of a personal conversation with his parents and information received from the teachers of the school or boarding school.

Information about whether the student (pupil) for whom the medical card is issued is under observation by a doctor

The next section of the child's medical record directly concerns children who need to be monitored by a doctor in a clinic at their place of residence.

Externally, the section of the child’s medical record form looks like this:

The purpose of filling out this section is to control the implementation of various dispensary procedures. The school or boarding school health worker transfers them to the child’s record from the clinic’s medical record. It is extremely important to fill in all the columns of this block with data. And if a student (pupil) is removed from dispensary medical observation, the date and reasons for deregistration of the student (pupil) must be entered in this section of the child’s medical record form.

How to fill out the section on treatment and preventive measures

The fourth section includes data on the implementation of mandatory medical and diagnostic measures, for example, on the dates, timing and results of deworming or on sanitation of the oral cavity in minor students.

Externally, the section looks like this:

Mandatory treatment and preventive measures

4.1 Deworming

4.2. Sanitation of the oral cavity

In the Russian Federation, in each institution, when observing a school student or kindergarten student, medical specialists are guided by the legislative acts of the Ministry of Health of the Russian Federation during their work:

• Etc. No. 60 dated March 14, 1995
• Etc. No. 186/272 dated June 30, 1992
• Etc. No. 151 dated 05/07/98

These legislative acts regulate the frequency of medical examinations and other mandatory medical measures for minor students and pupils. In the described section of the child’s medical record form, notes about the completion of these procedures are recorded with the addition of specific dates and types of events.

How to fill out the immunizations section of your child's medical record form

This section includes data from doctors about what and when vaccinations were given to a minor who was not observed by health workers. The section contains the dates and timing of immunization activities, regardless of the cases for which the vaccinations were given.

Section appearance:

Immunoprophylactic measures

5.1. Examination of a school student or kindergarten student before preventive and other vaccinations

In column (5.1.), the health worker indicates what diagnosis the student (pupil) had at the time of vaccination. If the presence of this disease clearly conflicts with the possibility of immunization, or is a direct contraindication for it, the medical record of a school student or kindergarten student indicates the date until which vaccinations are postponed. The child’s medical record also reports the name, dose and method of administration of the immunoprophylactic drug, as well as the series of the vaccine used. Subsequently, based on these data, the reaction of a school student or kindergarten student to vaccination is monitored. The results of the observation are also then entered into the children's medical record.

Data on whether a school student or kindergarten student has undergone routine preventive medical examinations

The sixth section is differentiated into 10 columns, which correspond to the periods of examinations of students (pupils) at different periods of their lives:

• before registration in a kindergarten group;
• one year before enrollment in school;
• before the actual enrollment of the student (pupil) in school;
• at 7 years old, at 10 years old, at 12 years old, at 14-15 years old, and at 16 and 17 years old.

Data from routine medical examinations (6.1 - before entering a nursery school, kindergarten, 6.2 - 1 year before secondary school, 6.3 - before secondary school)

As part of the mandatory medical examinations, health workers enter the results of external and laboratory examinations of the student (pupil) into the columns of this section of the child’s medical record:

• Student blood pressure and heart rate indicators
• The final conclusion is that the school student or kindergarten student is healthy. If such a conclusion cannot be made, its clinical diagnosis is entered.
• During each medical examination, a school student or kindergarten student must undergo urine, blood, and stool tests

Based on the results of the medical examination, the examined student (pupil) is assigned to the required health group. Then follows the conclusion of the conclusion about his state of health - both physical and mental.

Results of medical prof. consultations

In the section of the child’s medical record form dedicated to the results of medical examinations of the student (pupil) and consultations with a doctor, information is entered that is based on current data - the results of medical examinations and conclusions after monitoring the children.

Section dedicated to the results of medical consultations and recommendations

In the column with the name “Professions”, those variants of professions that the student (pupil) is going to master and subsequently use are entered; the reference point is his words. The “Recommendations” column contains the conclusion of the local pediatrician, based on an assessment of the condition and degree of health of the minor, the problems the student (pupil) has, the presence of diseases or any deviations, if any.

Form 025/у 04 was put into circulation in 2004. The form was developed by the Ministry of Health. Approving document - Order number 255. An outpatient medical record, form 025/u 04, is used by institutions providing outpatient care (without providing a bed).

Form 025/у 04 is filled out during the patient’s initial visit to an institution or when visiting a home to provide medical services. One copy of the card is created for one patient in one institution. If a patient is seen by several specialists, they use the same document to keep records. Duplication of primary documentation would inevitably introduce confusion into the medical history and complicate treatment.

Outpatient card form 025/у 04 can be used by any medical outpatient organizations, regardless of location or specialization. The form is used by FAPs and health centers. The location of the form is the clinic reception. Here you can fill in the information on the title page.

Medical record form 025/у 04 is a landscape-type card, including a title page and internal pages for entering information. When printing, the form is made in full accordance with the form. Changes to an existing document are not permitted.

Card form 025/у 04 contains important personal information about the patient. The document includes not only basic passport data, but also telephone numbers that allow you to contact the patient, and information about the place of work. The insurance policy number and SNILS must be entered. For people who have any benefits, you must also enter the benefit code. If there is a disability, the corresponding column is filled in. Form 025/у 04 also includes information about a change of address and place of work.

For a medical institution, a medical card (form 025/у 04) is the main document of a citizen receiving outpatient services. The form contains up-to-date information about the patient’s main diagnosed diseases. Information about the presence of existing diseases that are subject to dispensary observation is entered in the appropriate columns. This is an important resource for the attending physician.

Information about such patient parameters as blood type, Rh factor and drug intolerance is also important. These data play a major role in the provision of certain types of emergency care and surgical interventions.

The map contains loose leaves that describe the dynamics of the disease. All visits or services provided at home are recorded. The form also records cases of issuance of certificates of incapacity for work. During treatment, the patient may require hospitalization in an inpatient clinic. In this case, form 025/у 04 is transferred to the hospital for the duration of treatment and is added to the main medical record of the patient in the hospital.

Buy an outpatient medical card form 025/у 04

You can buy a patient’s medical card form 025 from 04 in Moscow at the City Blank printing house. We can produce outpatient card form 025/у 04 in a single copy or print a batch of the required size. A certain number of forms may be in stock. Check availability with managers.

You can pick up your medical card in person when you visit our offices. You can order courier delivery to your door. We also cooperate with the largest shipping companies, and can send purchases to any region of Russia. Postal delivery to the desired location is possible.

The forms of certificates can be very diverse and depend on what specific team the person will be in. Our country has developed a whole system of documents for these purposes.

In this article we will study the issue of registering and obtaining a certificate, without which a child cannot be admitted to kindergarten. Attending preschool educational institutions is an important step in the life of both children and their parents. Therefore, you need to know exactly what is needed for your baby to start going to kindergarten. We will talk about the child’s medical record form 026/u, since parents are interested in what information it should contain and how it is processed.

The child enters kindergarten and school on the basis of the Order of the Ministry of Health of the Russian Federation. It is recommended to collect medical documents 1-2 months before the date of his first visit to a general education institution.

Let's consider the medical documents necessary for enrollment in a school or kindergarten. These include:

F-63 preventive vaccination card;

Medical card F-026u;

Vaccination certificate (blue book);

Information about the epidemiological environment.

Why do you need a medical card?

Form 026/у is required for a child to be admitted to a kindergarten or general education institution. Carrying out the examination required to obtain a card is an important point not only for avoiding the outbreak of epidemics in a group of preschoolers, but also for monitoring the health status of children. That is, in essence, this is a preventive measure. It must be remembered that timely detected pathology gives a high chance of its complete elimination without consequences. What else does a child’s medical record provide?

If health problems are identified

In addition, if during the examination a child’s health problem is diagnosed, he may be sent to a specialized preschool institution, and parents will receive special recommendations on further actions. If vision problems are detected, parents are advised to consider the option of a special kindergarten for children with such pathologies. Such recommendations are not something terrible; on the contrary, they are aimed at ensuring that the child receives specialized assistance in restoring vision. Such kindergartens focus their activities on improving the health of children with vision pathologies.

If a schoolchild is diagnosed with pathologies that do not allow high-intensity physical activity, the pediatrician may issue a special permit not to attend physical education classes at school. It can be either temporary, until the problem is resolved, or permanent.

Visiting specialists

The main question for all parents is which specific specialists need to be visited to obtain a certificate. The child’s medical record involves consultation with a wide range of doctors. To obtain it, first of all, you should visit a pediatrician. He will issue the necessary referrals to specialists, including tests.

List of doctors

Typically, the list of required specialists includes:

If a child suffers from any chronic diseases, then, at the discretion of the pediatrician, referrals to other specialized specialists, such as a speech therapist, gynecologist, psychologist, endocrinologist or andrologist, may be issued. The Ministry of Health recommends seeing a gynecologist for girls and an andrologist for boys starting at age 14. This is necessary even without indications, for the prevention of sexually transmitted diseases and pathologies in the reproductive system. It should be borne in mind that these specialists are not included in the list of mandatory visits, and the examination can only be carried out in the presence of the child’s parent.

Taking tests

In addition to visiting and consulting with specialized specialists, to obtain a child’s medical card, it is necessary to undergo a number of tests. As a rule, these are standard studies:

1. Blood and urine for general analysis.
2. Feces for worm eggs and other protozoan organisms.

As a rule, research results are provided a few days after delivery. This depends on the workload of the outpatient laboratory. After receiving all the test sheets, a second visit to the pediatrician is required to draw up a card. After this, it must be signed by the chief physician of the clinic. The document is provided to the kindergarten at the request of the preschool administration. A sample of a child's medical record is presented below.

It is considered optimal to give it a month before the child is expected to attend kindergarten. The certificate must be submitted to the school before the first of September, otherwise the child may not be allowed to attend classes. Thus, it is necessary to take into account the time it takes to issue a card in order to provide it in a timely manner at the place of request.

The child’s medical record 026/у is signed by the chief physician of the medical institution only if all tests have been passed.

How to properly prepare for tests?

To avoid having to repeat analyzes due to unreliable data, it is important to follow certain recommendations when preparing for them. These standard tips include:

1. Urine must be collected in special sterile disposable containers. Before collection, you need to carry out hygiene of the genitals and blot them with a towel, and then collect the mid-morning portion.
2. Blood sampling should take place in the morning on an empty stomach. The analysis is carried out by piercing the finger with a special scarifier. Some parents prefer to purchase this needle themselves at the pharmacy.
3. Feces are also collected in plastic disposable containers, which are sold in every pharmacy.

Documents for registration

When the commission for issuing a child’s medical card for kindergarten, form 026/u, takes place at the clinic at the place of residence, only the child’s insurance policy is required. Specialists will be able to find all the necessary information in the child’s development card stored in the clinic, including birth data and vaccination card. If you choose a private clinic, you will need to provide a package of documents including:

1. Parent's passport.
2. Child's birth certificate.
3. An extract from the card at the clinic listing the vaccinations performed.
4. A card of the child's developmental history or an extract made by the local pediatrician.

Data on the card

The child's medical card form for the kindergarten is filled out by a nurse or pediatrician. The following information is indicated on the front side of the document:

1. Last name, first name, patronymic of the child.
2. Date of Birth.
3. Place of permanent or temporary registration.
4. Parents' details, including full name, place of work and telephone number.
5. Vaccinations performed and reactions to them.
6. Allergy (if any).

Each narrow specialist fills out his own column in the medical record after examination and consultation. When all indicators are normal, a “healthy” mark is placed in a special column. If there are pathologies, the specialist enters data about them into the card and makes a decision on whether the child can attend the kindergarten under general conditions.

How much does it cost to obtain a child’s medical card for kindergarten?

Inspection options and costs

A medical examination is carried out free of charge at the children's clinic at your place of residence. This process is quite lengthy, sometimes taking more than a week, which is due to a discrepancy between the schedules of local specialists. Also, testing in public clinics takes quite a lot of time. This is due to the poor equipment of laboratories in the clinic and their abnormal workload.

There are cases when schoolchildren are offered the option of undergoing a medical examination directly at the educational institution. It's also free and obviously convenient for both the child and the parents.

It is possible to obtain a child’s medical card on a private basis in a non-governmental clinic. The main advantage of this option is speed. If you make an appointment with specialists in advance, you can receive the necessary document the very next day after your application. With this option, it is possible to see specialists even within one hour. However, you will have to pay a lot for such a high speed of service, since the price will include consultations with specialists and laboratory tests.

The average cost of a medical examination is from three thousand rubles. It all depends on the chosen clinic. Private medical institutions offer comprehensive examinations for a certain amount. However, before using such offers, carefully study which specific specialists and examinations are included in the price, so that you do not have to pay extra in the future for the necessary consultation. The purpose of undergoing a medical examination is not only and not so much to draw up a card, but also to prevent diseases and pathologies.

We reviewed the child’s medical record form 026/у.

FILLING IN THE TITLE SHEET OF THE MEDICAL CARD OF AN INPATIENT

OKUD form code_______________

Institution code according to OKPO________

Ministry of Health Medical documentation

Form No. 003 U

The name of the institution is approved by the USSR Ministry of Health

___________________________№ 1030

Date and time of receipt

Date and time of discharge ___________________________________

Department ____________________ ward No. _______

Transferred to department _______________________________________________

Number of bed days spent ________________________________________________

Types of transportation: on a gurney, on a chair, can walk (underline)

Blood type____________ Rhesus affiliation_____________________

Side effects of medications (intolerance)

1. Last name, first name, patronymic: _____________________________________________

2. Gender: ____________

3. Age: ____(full years, for children: up to 1 year - months, up to 1 month - days)

4. Permanent place of residence: city, village(emphasize)

5. Place of work, profession or position __________________________________________

for students, place of study; for children - the name of the child care institution, school; for disabled people, gender and disability group, JOB - yes, no (underline)

6. Who referred the patient: ___________________________________

7. Delivered to the hospital for emergency reasons: yes, no - ________hours after the onset of the disease, received injuries, hospitalized as planned (underline)

8. Diagnosis of the referring institution: _____________________________________________

9. Diagnosis upon admission_________________________

10. Clinical diagnosis______________________ Date of establishment __________________

11. Final clinical diagnosis

a) main ______________________________________________________________

b) complication of the underlying ___________________________________________________

c) accompanying ________________________________________________________________

Goal: ensuring continuity in the actions of health workers.

Note: by the time the shift is handed over, all manipulations prescribed to patients must be performed by the nurse handing over the shift.

Algorithm of actions

I. The nurses receiving and returning duty, together with the head nurse of the department, must:

1) make a tour of all wards with a report on patients in serious condition;

2) inspect the sanitary condition of the ward, ask the patients’ opinions about the last duty (are there any complaints or suggestions);

3) accept medical documentation:

a) a journal of medical prescriptions;

b) log of reception and delivery of duties;

c) registers for drugs of list A and B along with the keys to the safe in which they are stored;

4) donate medical instruments: thermometers, tonometers, syringes, etc.;

5) re-examine the medicines at the post;

6) both nurses are present at the medical conference; the nurse handing over the shift reports on the dynamics of the patients’ condition, the past shift, reports a summary of the movement of patients during the day;

7) the nurse on duty fills out in the morning the “Sheet for recording the movement of patients and hospital beds” and the “Portion requirement” in two copies - for the catering unit and the dispenser

DRAFTING PORTION REQUIREMENTS

Goal: patient compliance with the diet prescribed by the doctor.

Portion requirement forms f No. 1-84.

for meals for patients in the therapeutic department at ________________________________

(date, day, month, year)

Information about the presence of patients as of 10 o'clock

(day month Year)

1. Select the numbers of therapeutic diets for each patient from the assignment sheets.
2. Add them to the general list of patients at the post.
3. By 9 o'clock, provide the head nurse with information on the number of patients, excluding those who are being discharged today, as well as the number of people eating at each treatment table and the additional food prescribed.

1. Indicate in the portion plate the name of the department, the number of patients at 10 o'clock, and the date.
2. Enter into the portion register the number of people eating at each table and information about the additional food prescribed. Sign the portion request from the head of the medical department.
3. Submit portion requirements to the diet service and canteen.