Why you need a clinical account
Medical records are necessary to improve the monitoring of patients with chronic diseases, risk factors for these diseases, as well as for people with acute illness. It allows you to optimize the performance of dynamic monitoring of patients to monitor the effectiveness of therapy, for the assessment of symptoms in order to prevent recurrence of the disease, and in some cases with the aim of further examination and diagnosis. Citizens standing at the dispensary, are supposed to free provision of medicines and some other benefits.
Patients put children with chronic illnesses, and often chronically ill, if the child is ill SARS more often 6 times a year). Registration is performed by our pediatrician. The basic document in which the doctor reflects the dynamics of dispensary observation of the patient is the "Medical card of ambulatory patient" (UV 025/y). In this case, on the backs of these documents is the cipher of the disease that the patient is at the dispensary, or the letter D.
Maintaining dispensary records
When setting patient patients primary doctor fills out the medical report (opinion of condition) on the basis of survey data, at the end of the year it is staged case history, which should address the following points:
- the original condition of the patient;
- scheduled and conducted treatment and preventive measures;
- the dynamics of the disease (status change, decrease/ increase in the number of exacerbations and the change in the number of disability days);
- the results of the evaluation of health status (improvement, worsening, no change).
Frequency of visiting medical institutions for the purposes of follow-up and additional tests determined by the treating physician taking into account the severity of violations and the frequency of exacerbations. Doctor regularly updates a map of the results of examination of the patient, the prescribed treatment and its adjustment, makes recommendations for employment and other information. If the patient refuses medical examination or surveillance, the decision is recorded in the medical record, shall be signed by the patient, as well as printing of physician of medical institution. The systematic failure of the patient in the calendar year of nomination and advice and if the person had not visited a physician in the course of the year, he may be removed from the dispensary with an indication in the medical records the reasons for withdrawal.