Medical documentation. Filling and storage

Medical facilities include public hospitals and polyclinics, offices in schools and kindergartens, private clinics, maternity homes, dispensaries. Each institution is obliged to keep records of examinations, medical measures, sanitary and preventive measures taken. In addition, medical records include accounting and reporting forms. The unified documents are fixed by the Ministry of Health of the Russian Federation. If a particular medical institution requires its own medical documentation, then the chief doctor approves it.

In unified forms, the type of a particular document, the format, and the terms of its storage are indicated. The completed reporting forms should be correct, reliable, timely, with the maximum completeness. Standardized execution of primary documentation on paper facilitates its further processing in electronic form, accounting and analysis. This, in turn, is important for planning activities, analyzing the work of staff, assessing the workload of medical institutions, the effectiveness of their activities, providing statistical data to the regulatory authorities.

The documentation is kept in accordance with the law on medical confidentiality. Information contained in it is not allowed to be disclosed to third parties in the same way as it is not allowed to transfer such documents to anyone. Of course, in a number of cases, exceptions are possible:

1. Upon request, copies of the required forms may be provided to the patient, but not the originals.
2. With the consent of the person, data from his documents can be transferred for publications, research, training.
3. If a citizen can not make a decision because of his state of health, it is allowed without his consent to provide information only for the purpose of his treatment.
4. The transfer of information to third parties is also possible in cases when there is a danger of mass spread of infectious diseases or poisonings.
5. The consent of the minor patient to the transfer of information to his parents or guardians for further treatment is not required.
6. During the trial, medical records can be transmitted at the request of the relevant authorities.

Conditionally, all medical documentation can be divided into several types:

1. Documents describing the patient's condition, diagnosis, medical appointments during the observation period in one of the medical institutions. Examples include "Outpatient or inpatient card", "Birth history", "Individual card of a pregnant woman".
2. Documents providing communication between different medical institutions As a rule, they carry information about the current status of the patient and the need to take certain measures (for example, "Extract from the medical card").
3. Documents reflecting the work of the medical staff directly ("Journal of Procedural Accounting", "Journal of Medical Records").

It is also possible to divide all documents depending on the institutions and specialists using them. This includes, for example, the documentation of a speech therapist, a gynecologist, forensic medical institutions, an ambulance station, and so on.