- Our electronic card, if it has already been created, is not open to the entire curious public. Medical confidentiality will remain so and will remain so. There is no need to type your name on the Internet; fortunately, this will not give you anything.
- But if you want to see all the correspondence between your condition, the services received and what is written on the card, you need to go to the clinic to which we are attached. And there you can talk with your local and attending physician. He will tell you at what stage the map development is. And it will probably show the pages on the monitor screen.
If there is such a need, then you need to take a coupon for an appointment with a local therapist and already at the appointment voice your desire to see it, you can approach the head nurse (you will get to her faster than a doctor) with such a request - they will not refuse. But the electronic card will have the same thing, the same data as the paper card.
An electronic card is not a document that a patient can see in the public domain until the electronic system is adjusted. Not all doctors yet have computers in their offices, there are no terminals for electronic insurance policies, and doctors protect diseases from the patient himself. Regular card They don’t give it to you, and they won’t even give you an electronic one now. Until they decide how to encrypt data that the patient does not need to see.
And the most interesting thing is that the patient must collect the data for the electronic card himself. That is, it will no longer be the same card that is kept in the clinic.
That is, doctors see on their computers all the patient’s illnesses, how sick they were, where they were treated. But the patient can only see the names of the diseases.
Doctors are against patients seeing the drab work of doctors, and doctors are against frightening patients with scary names of diseases.
But you can try to see it in the therapist’s office if he agrees to print out your medical history for you.
To be honest, I didn’t even know there was such a thing new opportunity view your electronic medical record. It turns out that the attending physician does not have the right to refuse you, and at your first request he should, without any questions, transfer the information available about you about your state of health to your flash drive or portable hard drive.
My relative works in one of the hospitals as a programmer. It was he who began to implement, as Tew correctly writes, this Samson information program. I asked him everything). It's like this special program all around Russia. Doctors enter all the information about patients into the computer into this program. And in Moscow, for example, they can come in and immediately read everything and give advice or comments. He also says that doctors still keep medical records by hand, because this way there is more trust. Electronic medical records are not shown to any of the patients, and patients do not ask about these records because they do not know about them).
Electronic medical records, as planned by experts, should replace paper ones, which from time immemorial doctors and nurses filled out and now fill out on their own. Information systems have now been introduced that allow you to see medical electronic card any patient in any city that is already covered by this system. But this is available only to those specialists who have access to this unified information system according to their position. Still, no one has canceled medical confidentiality; it remains.
If a person has the password, he can view the cards entered into this system.
And if he doesn’t have it, then only through his attending physician can he try to look at it.
I think that the electronic medical record can be shown by the attending physician or by order of the chief physician of the hospital upon presentation of a passport. But while people still know little about such subtleties in medicine, they use handwritten medical records when necessary.
Medical electronic records have been introduced in Russia since 2013. Several software products have already been developed - information systems, such as Samson or Medialog. They are now in different regions They are being tested to select the best one and make it uniform throughout Russia.
Electronic medical records are one of the modules of these information systems. They are analogues of medical histories, which in most cases are now still written by doctors by hand. Here you can read what an electronic medical record is. I’m somehow not sure that such documentation can be available to patients. Still, patients are not allowed to hand over a handwritten medical history; they are carried from office to office by a nurse or nurse, but not by the patient himself. There is the concept of medical confidentiality, which the doctor is obliged to keep. So I don’t think patients will be allowed access to the electronic medical record.
The page for this map looks like this:
Even from this picture it is clear that there may be little interest for a simple patient here. Everything is laid out professional language with special terms.
Although on another site, here, there is an indication of Patient's personal account, as a separate online service:
Perhaps, after registering through your Personal Account, you will be able to receive some information about test results, diagnosis, procedures, etc. But for this to happen, the service needs to be made available to the public.
Electronic medical records are designed to allow a doctor in any hospital or clinic to have access to a patient's medical history. They started implementing them back in 2013 and promised to completely switch to them in 2014.
But, unfortunately, even today, in 2016, not all regions work with EHRs.
To ensure the privacy of the data stored on the card, it is password protected. Doctors have access to the password. It should also be possible to access the card through the Patient’s personal account. But, unfortunately, today it is practically not implemented. Therefore, the most acceptable option now is to ask the doctor to transfer the card information to an electronic medium (flash drive).
If there is a need to view your electronic medical record (EMR), you can contact your local or attending physician and he will dump its contents onto your flash drive, and perhaps show the pages you are interested in on the monitor of your work computer. For example this:
In order to view your electronic medical record, you need to contact your local doctor at your place of residence, since the information is only on his computer and is not posted on the social network.
Electronic medical records were introduced in Russia not just yesterday. However, this system does not yet cover all settlements, of course. I am almost sure that a resident of a small remote village will not be able to view his electronic card even if he wants to. Technical capabilities are not enough.
As for larger places, you need to know:
Fact 1. A paper duplicate is still needed
The standard for maintaining an electronic card is enshrined in GOST R 52 636–2006, and records that comply with this GOST have the status of an outpatient card. But, since the order to maintain a paper outpatient card is still in force, it is not yet possible to limit ourselves to only the electronic version. Most often, information is duplicated in ordinary paper cards, which makes it possible to transfer data to other health care facilities that are still not equipped with a computer system or maintain electronic cards using a different program. The simplest option is to periodically print out data from the information system and enter it into a paper map.
Fact 2. Multi-accessibility
The clinic database is structured like this: in the health care facility they create local network with centralized management, similar to the Internet, protected according to the requirements of the law on maintaining medical confidentiality. There is a central server where all patient information is stored, divided into individual folders. From computers at workstations, you can view or change the contents of any folder at any time, depending on the access level. Thus, the patient’s “page” can be simultaneously filled out by different departments and specialists, for example, an ophthalmologist, a radiologist and a laboratory doctor who enters test results into the card. There is no need to move the card from place to place, there is no need to hand it out to the patient each time and track its return.
Fact 3. EHR simplifies many processes
With an electronic card, your life history is always at hand; it is available in a special tab or via a quick link. This will definitely simplify and speed up working with elderly patients with mnestic disorders. Also on the patient’s page you can see a list of updated diagnoses, a list of appointments and consultations, an allergy history, and data on the carriage of infections. Without digging through a paper map, without deciphering your colleagues’ handwriting, without searching through pieces of paper folded in half, you can quickly get acquainted with the results of examinations. You can book your appointment by filling out a special form, which can be customized individually. You can attach a drawing or photo to the inspection, the results of the manipulations performed. It simplifies the computer and the issuance of appointments and directions (the part of the appointment containing recommendations is automatically printed), as well as filling out coupons and encrypting the diagnosis according to the ICD.
Hippocrates never dreamed of medical cards, medical and childbirth histories, much less electronic versions of these documents! Read on to learn how the electronic future is invading hospitals and clinics.
An electronic medical record, or electronic medical record (EMR), is an electronic document intended for maintaining medical records, searching and issuing information upon requests (including through electronic communication channels).
The task of the Uniform State Health Information System is to promptly obtain information on volumes medical care services provided to the population to make it easier for the state to plan medical costs and optimize the expenditure of budget funds. In the future, the Uniform State Health Information System will become very convenient for practicing doctors. If we can get it to work, consultations, hospitalizations, and transfers will be easier to process
Fact 4. EHR strengthens control
The use of electronic records makes the work of a medical organization more transparent in every sense. At any time, each record can be checked by management, insurance company, and supervisory authorities. Competent and timely internal control allows you to get closer to impeccable documentation, which will help you avoid penalties during external audits.
Fact 5. Patient access will be denied
With a complete transition to electronic documentation, patients will not have direct access to their outpatient records. The patient will not be able to take the card home for his own personal reasons or remove the results of studies or tests from it, which is convenient for the clinic, which in this case will not face fines if this card is requested for verification. The information system, if necessary, allows you to quite simply and quickly print out a statement for the patient. There are projects for more technological solutions, for example, a special memory card in the hands of the patient, duplicating the outpatient card.
Fact 6. EHR will be implemented everywhere
The creation of a unified medical information system is a state initiative, which is recorded in order No. 364 dated April 28, 2011 “On approval of the concept of creating a Unified State Information System in the field of healthcare” (Uniform State Health Information System). So sooner or later computerization will be introduced everywhere.
Fact 7. Grandiose plans
Federal-level services planned in a unified information system, for example, an integrated medical information record, imply a much higher level of storage and transmission of medical information than is currently the case. For example, if emergency or emergency hospital doctors have the opportunity to review a patient's outpatient record, this could save many lives.
What do you think?
I really like the electronic card, even though the transition to it was difficult. It is not possible to implement all functions at once, but we are getting there. Now we use it not only to keep track of cards, but also to track doctors’ working hours, payroll calculations, and a warehouse. There are many problems with training experienced specialists who come from regular clinics and have not worked on a computer. They are afraid. And young people get right up and work, they, of course, also have shortcomings, but we work, we check, it’s still easier than with paper.
Deputy chief physician for clinical expert work, polyclinic in the Moscow region
In general, in institutions that maintain an electronic medical history or outpatient card, the level of documentation is much higher. Apparently this is due to the fact that primary documentation Someone from the clinic administration is seriously checking.
Tatyana, medical expert at an insurance company
Still, there is no feeling of reliability from the electronic card. We’ve gotten used to cards over many years; I picked up the card and started accepting it. But on the computer you click on something wrong, and it just goes away and gets deleted, or someone else edits the map — then look for the loose ends. And it turns out to be awkward with patients. You can write a card almost without looking, but asking a patient and looking at a computer is somehow impolite. Again, if the patient has already left, the next one will immediately come in; you can put the paper card aside and return to it later, but with an electronic card it is more difficult. By the end of the day everything will be mixed up and you won’t be able to put it back together. Life doesn’t stand still, maybe we won’t be able to do without a computer later. It’s already convenient with analyses—everything is with numbers, printed, directions are drawn up by themselves.
Olga, general practitioner highest category, work experience 16 years
The electronic map is not perfect, but it is better than scribbling. Checking boxes, instead of writing the same thing a hundred times, still saves a lot of time. But for now you have to print out the appointment, sign it and stick it on the card — this doesn’t make much sense. Moreover, if the patient came, for example, only for a rinse, he still has to register it as an appointment so that the insurance company will pay for it, and this is not very convenient. But in principle, filling out a card is no more difficult than filling out a page on a social network, so there are no problems with the database.
Larisa, ENT doctor of the first category, 11 years of work experience
In the near future, an electronic medical record for an outpatient patient can significantly ease the work of clinic staff. Paper versions of maps will be gradually phased out.
What is a medical record in 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 clinics. The EHR was developed for greater convenience and ease of professional activity second. In addition, it allows you to significantly simplify the activities of the organizational, methodological and statistical departments of any medical institution.
The most important thing is that the electronic medical record can include exactly the same information as its paper counterpart.
Operating principle of EHR
IN Lately All medical and preventive institutions strive for maximum computerization. For the same purpose, an easy-to-use EHR was developed, the use of which greatly simplifies the work of medical staff and the lives of patients.
The EHR is designed quite simply. It is contained in an electronic file cabinet, which is part of a special program for automating the workplace of a certain medical specialist. To gain access to some specific map the doctor or nurse must simply 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 person’s year of birth or address of residence. If the card has already been filled out, then it will contain a fairly large amount of information that relates to a specific 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 medium allows you to easily familiarize yourself with every diagnosis that has ever been made to the patient. Now, in the age of computerization, this is very relevant.
It should be noted that a modern EHR for an outpatient would not make much 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 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 represents a unified medical base.
Why was an electronic medical record created?
The purpose of creating an EHR
EHR has become 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 large volumes of paper documents that have a huge number of shortcomings. In addition, a unified EHR significantly simplifies the activities of medical hospitals, which are now able to request information related to a patient entering treatment in a digital format. This opportunity greatly simplifies their work - 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 EHR over a paper map
It is worth noting that the EHR 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, information is always available directly to the clinic.
The next advantage of an electronic card is that there is no need to search for it and then transfer it to a specific specialist by the registry. All data is always available to the doctor on his computer.
Another undoubted advantage of the EHR is that there is no need to constantly paste additional sheets, advisory opinions, research results and analyzes into it. All such information is entered into certain columns of the program, which provides the necessary information upon the doctor’s first request.
Several clinic specialists can view the contents of an inpatient’s electronic record at the same time. In this case, it is possible not only to simultaneously read the card, but also to fill it out. This feature allows you to significantly optimize the activities of the staff of a medical institution.
Disadvantages of EHR
Like any other modern invention, an 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 that should be noted is the possibility of computer scammers stealing valuable information. In addition, a patient's electronic record 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 mandatory staff training is required. correct 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 various innovations, especially those related to working with computer equipment.
Challenges encountered with universal adoption of electronic health records
In addition to the problem of staff training, there are some other difficulties. First of all, we're talking about about the need to equip the workplaces of all doctors and most nurses with computers. For this purpose, the management of the medical institution has to spend significant amounts of money. However, this problem is gradually being solved, albeit not as quickly as we would like.
A much bigger problem is the transfer of all necessary information from paper 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 do such a large amount of work. Quite often, the doctor does not even have time to fill out an electronic card, let alone digitize existing data. If we consider the reception staff and nurses, they do not have the appropriate knowledge to fully transfer specific data. The assumption that no one will hire additional employees will also be correct.
Probably, this problem will be solved in the following way: during the first few years after the mandatory introduction of the medical record form, parallel maintenance of both electronic and paper records will be carried out. However, this approach can also bring a lot of inconvenience to doctors and nurses. Thus, before creating and introducing an EHR, it is necessary to find an effective solution to this problem.
EHR development prospects
An electronic card is created with the aim of subsequently fully optimizing the activities of medical institutions. It is expected that in the future the system will undergo serious development and there will be no need for a regular registry. It will be replaced by an electronic registry.
This will free up significant labor resources and increase the number of pre-medical surgeries. 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 still some promising direction that involves the development of an electronic medical record. The creation of a universal, unified EHR will make it possible to obtain 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 into a network all medical institutions in the country. 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 located several thousand kilometers from the attending physician will be able to obtain complete information about the patient’s medical history in just a few minutes. Such a system, in addition, eliminates various frauds with some medical documents.
Electronic registration can be very convenient.
Protection against equipment failure
In fact, the most serious problem remains the possibility of failure of the equipment, that is, the computer on which a single database will be located containing the 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. This technique will allow you to avoid serious difficulties when medical personnel work with electronic records.
Another suitable solution is to place database backups in cloud storage. However, this technique has a significant drawback - it will be easier for various Internet scammers to access information located in online storage.
What is the benefit for the patient?
Creating a patient's electronic health record offers significant benefits to the patient. Firstly, every 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 facility, 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 simpler in the near future. The patient only needs to make an appointment with a specialist. When visiting the clinic, you will need to present your card health insurance, and then you can immediately go to the doctor whose consultation he needs.
What else is interesting about a patient’s personal electronic medical record?
The next benefit that the patient receives is confidentiality. Information about the doctor's appointment, the diagnosis and the results of medical research will become inaccessible to representatives of junior medical staff. The problem is that with a modern system of recording and data storage, medical records, as a rule, are located in the registry. The employees working there have full access to the maps and can look at absolutely any one, not only for their own interest, but also at someone else’s request. New system storing patient medical data will completely eliminate this possibility.
Time frame for the implementation of the project to implement the EHR system
In fact, the full introduction of electronic patient medical records and the cessation of maintaining paper records in clinics was a foregone conclusion even 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 beginning significant problem it was impossible to fully equip clinics with appropriate technical means. Then the need for staff training arose. On this moment this problem has been practically solved, however, there is a need to ensure that the program runs without failures. It is expected that this obstacle will also 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 introducing 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 large energy costs, but the overall savings will still be significant.
Introduction of unified regulations for maintaining electronic patient records
At the moment, the developers of the above-mentioned system are striving to implement certain measures to fully systematize 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 an electronic medical record for an outpatient patient has been developed, but several. And there are also several possible unified storage systems.
Such options were being explored not only by representatives of medical institutions and universities, but also by 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 is 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 gain access to information about the patient who came to see him in a matter of minutes.
Despite the existing shortcomings and obstacles to the introduction of the EHR system, developers strive to effective solution problems and the fastest possible transition from paper maps to electronic ones.
Correctly filling out a patient's outpatient card has great importance for doctors, since it is in it that all information about a person’s disease is stored. The map also becomes evidence in legal proceedings, if any arise. With the help of this document, a medical examination and verification of the work of specialists are carried out. For insured people, the medical card will serve as confirmation of the insured event.
Valid card form
In 2015, the Russian Ministry of Health issued a new order (“On approval of unified forms of medical documentation used in outpatient settings and the procedure for filling them out”), according to which all medical documentation and the rules for filling it out were 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 the sick person, since it now contains specific points and sub-points. They must be filled out in mandatory. Until 2014, patient records were not made in such detail by different doctors. The order obliges to record information about consultations with doctors and managers. It is mandatory to record the meeting of the commission of medical specialists. Specialists in a medical institution are required to keep records of patient X-ray exposure. If a sick person needs to seek help from 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, the employee at the reception fills out the cover page of the card being issued. The title page contains detailed information about the patient. Entries in the outpatient medical record itself will be completed directly by medical specialists. Employees of the institution who have secondary medical education, are engaged in entering information into the register of patients who receive assistance.
The serial number of the sick person’s card is indicated on the title page of the document. 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 carried out by specialists. When describing 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 required to make notes in the chart for each patient visit. Entries on the territory of the Russian Federation must be made in Russian (carefully and without any abbreviations). However, the names of drugs can be written in Latin letters. If the doctor made a mistake, it must be corrected immediately, and then this place in the text must be certified with a seal and signature. Each doctor has his own personalized seal, through which such actions are carried out. A sample outpatient card is presented below.
Some have a thicker card, some thinner. It all depends on the number of illnesses suffered and visits to specialists. A complete description of the disease picture and symptoms will help make the most correct diagnosis for a sick person. Sometimes it is necessary to consult several doctors of different specializations to make a diagnosis. In the vast majority of cases, information about a person’s tests is needed. All this data should be displayed in the medical record. Based on the conclusions of specialized specialists, the therapist will be able to make the correct diagnosis. It often happens that a person’s symptoms and pain can relate 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 filled out in detail. To fill out, a person must present a passport to the employee if he is a citizen of Russia. If he is a sailor, then a sailor's certificate will do. Military personnel must present a military identification card Russian Federation. If a foreign citizen comes to the clinic, he has the right to present his passport or other identification document specified in the International Treaty. To visit a medical facility, a refugee must use an application as well as a refugee certificate. Stateless persons can apply to the clinic. For them, a mandatory document is a temporary residence permit.
The patient’s position and place of work must be indicated, but according to the person’s words (certificates from work are not required). Also, when registering an outpatient card, reception staff additionally request an INN and SNILS. Filling title page is not a complicated procedure, since there are hints about the information in each column in small print. To visit a primary care doctor, a person must provide information about their place of residence. Depending on the address, the patient is assigned to a specific doctor, as the territory is divided into streets. Sometimes a person goes to the clinic at his place of residence, and not at his 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 enshrined at the legislative level, but has already begun to function. The project is currently undergoing a pilot launch. An electronic card 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 field.
This service will be intended to store all information. Access can only be granted to persons authorized in this program. Also, the electronic medical record of an outpatient will contain all the information from the various medical institutions where this person went. In order for all information about a patient’s visit to the clinic to be stored in the system, it must be entered and recorded correctly.
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, etc. Their data.
- Vaccination.
- Diseases that have social significance.
- Disability, the reason for its occurrence.
Since this information is personal, protection from unauthorized intervention is necessary. For this purpose it is used electronic signature employee.
Persons using the program:
- Medical institutions, doctors, specialists. Employees of medical institutions who use the program are required to maintain medical confidentiality. They also enter information into the electronic map.
- Patients. They only have access to their own medical records.
- Other persons to whom anonymized information may be provided for statistics, analysis, as well as for further planning of actions in the field of health care.
Card filling quality
The Law of the Ministry of Health of the Russian Federation does not prescribe the specific content of specialists’ notes in the outpatient card, but they all must have a certain sequence, be thoughtful and logical. To avoid comments from regulatory authorities, it is necessary to describe in detail all the patient’s complaints. It is necessary to indicate how many days have passed from the onset of pain and discomfort to the first visit to the doctor. The doctor is obliged to characterize the disease and indicate the person’s condition 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 note must include a list of medications for the treatment of a sick person, referrals to other specialists, examination results, information on the provision of sick leave, various certificates, as well as information about the patient’s benefits.
In the same way, the specialist must fill out each patient visit correctly in the outpatient card. The card must also contain a signature indicating the person’s permission to undergo medical intervention or his refusal.
During the person’s return visit, the doctor must carry out the description in the same order. But it is also important to focus on the changes that occurred after the first visit of the sick person. Data on epicrises, consultations, and specialist opinions must be entered into the patient’s outpatient card. If a sick person dies, then a specialist must draw up a post-mortem epicrisis. It contains all the information about previously suffered diseases, surgical intervention, and the cause of death is stated. After this, a death certificate is issued to relatives this person. There are situations when it is difficult to determine the cause of death. Data from the map can help specialists figure this out.
Access to medical record
The information contained in the patient's outpatient record is a medical confidentiality. It is prohibited by law to disclose it, even if the person is dead. The fact that a person contacted a medical specialist is also not disclosed. The law allows certain individuals to provide information about patients without their knowledge. This is legal in the following cases:
- The patient is a minor or unable to express his will.
- Revealed infection may cause an epidemic or lead to infection of people who have been in contact with the patient (for example, when sexually transmitted diseases are detected, everyone who has had sexual intercourse with the patient must be checked).
- The patient's illness may affect the course of the criminal investigation.
However, lawyers, lawyers, employers, and notaries do not have the right to obtain information from the card without the permission of the patient himself.
Patient's rights
Patients and their legal representatives have the right to receive information from the card. Based on the data received, they can also receive advisory assistance 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, since there are no grounds for this. In the application, the patient does not need to describe the reason or purpose in order to receive an extract from the outpatient record. There should be no charge for photocopying information. The employee must log the presence of the statement for reporting purposes. At the moment, the law does 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 are also criminal penalties for providing incomplete or false information to a patient.
Peculiarities
Many patients are dissatisfied with the new form of 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 intended only for medical workers and their colleagues so that treatment is carried out professionally. The ordering 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 or she moves and leaves the clinic. In other situations, the card must remain in the medical institution, since it is the property of the clinic.
Extracts
Every person has a medical card, since it is registered in the name of the baby immediately after his birth. Sometimes a person needs an extract from an outpatient card. This document is called “certificate 027/U”. This certificate is often requested in kindergartens, when a child enters school, and also at the workplace. At work, this document may be requested to make sure that a person was really sick at some point in time.
Receiving the document occurs quickly. You need to seek help from a therapist or pediatrician in your area. Based on the information contained in the medical record, a certificate will be issued. In order for it to become valid, several stamps must be affixed. It can be difficult to obtain an extract from an outpatient card only if there are many diseases, since often the doctor must describe them all.
Sometimes receiving a certificate takes a couple of days. This may be due to the absence of specialists at the workplace to certify the extract. The stamp is affixed not by the attending physician, but by another employee. However, in many clinics a special employee is allocated for this or this procedure is entrusted to the reception staff. They are always present at their workplace, so there are no problems with certifying the extract. A sample extract from the outpatient card is presented below.
Conclusion
A medical card is a mandatory document for all people who go to the clinic to receive medical care. The outpatient card form is submitted at the reception desk. To register, a person must submit Required documents. The information contained in the medical record is a medical confidentiality. Patients cannot receive the original card. If necessary, the employee can make a photocopy of all data or issue an extract. If employees provide false or incomplete information, they will face administrative or criminal liability. Lawyers, attorneys and notaries do not have the right to obtain information from the outpatient card without the consent of the patient.
An electronic medical record has been launched, which will help systematize and combine all information about diseases and treatment of each patient.