Outpatient card: what is it and why is it needed?

What is an outpatient card? The answer to this question you will learn from this article. In addition, your attention will be provided with information about what is being created for such a document, what items it includes, and so on.

General information

The outpatient card is a medical document. In it, the treating doctors keep a record of the prescribed therapy and the medical history of their patient. It should be noted that such a card is one of the basic documents of the patient who undergoes treatment and examination in outpatient and out-patient settings. The form of the medical record is the same for all medical institutions. Such a document is established for each patient upon his first admission to the hospital.

Medical map and its role in practice

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

Incorrectly filled maps

If the outpatient's medical card has been filled in inaccurately or was lost by the registry, patients can submit substantiated claims to the institution. By the way, in some clinics there is such practice as deliberate loss of medical records. As a rule, this happens in case of poor clinical outcomes, mistakes in prescribing medications 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 possible to track the sequence of their changes quite easily, although the issued electronic card has no legal force.

Contents of cards

The medical card of an outpatient patient includes forms for prompt and long-term information. Let's consider their content in more detail.

1. Forms of operational information consist of formalized inserts for recording the patient's first referral to the doctor, as well as for patients with FLU, angina and acute respiratory illness. In addition, they contain inserts for a repeat visit, a phased epicrisis for the advisory commission. Such forms are filled in as the patient addresses the doctor at home or at an outpatient reception, and are glued to the root of the card.
2. Forms of long-term information contain warning signs, information about preventive examinations, sheets of records of already specified diagnoses and sheets of prescribing of any narcotic drugs. Such inserts are usually attached to the cover of the card.

Basic Principles of Mapping

An outpatient card is needed for:

• Description of the patient's condition, outcomes of therapy, treatment and diagnostic measures and other information;
• Compliance with the chronology of events that affect the adoption of organizational and clinical decisions;
• Reflection of physical, social, physiological and other factors that affect the patient throughout the pathological process;
• Understanding and compliance by the attending doctor with all the legal nuances of his activities, as well as the importance of medical records;
• Recommendations to the patient after the completion of the examination and the end of treatment.

Requirements for registration of the card

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

• Fill out the title page only in accordance with Order No. 255 of the Ministry of Health and Social Development of the Russian Federation of 22.11.2004;
• Reflect all patient complaints, medical history, clinical diagnosis, results of objective examination, treatment and diagnostic activities, repeated consultations and information regarding pre-hospital surveillance;
• To record and identify risk factors that can aggravate the severity and course of the disease, as well as the impact on its outcome;
• Record the time and date of each record;
• Provide sound and objective information that will protect the medical staff from possible Complaints or lawsuits;
• To specify any additions and changes with the date of their introduction and the signature of the doctor;
• In a timely manner, send the patient for social examination or a meeting of the medical commission;
• Justify the prescribed therapy for patients of a preferential category;
• For patients with a privileged category, provide for the issuance of prescriptions in triplicate, one of which must be pasted into the card.

Each entry is signed only by the treating doctor with a transcript of his / her name. No records are allowed that have nothing to do with helping the patient. All the marks on the medical record must be considered, logical and consistent. Particular attention is paid to those records that were conducted in complex diagnostic cases, as well as in the provision of emergency care.