Legislative framework of the Russian Federation. Instructions on the procedure for registering patients undergoing treatment in day hospitals of polyclinics, hospitals at home and day hospitals in hospitals

This instruction is mandatory for all medical and preventive institutions of the USSR Ministry of Health system.

Validity period: from the moment of approval.

For registration of patients admitted for treatment in a day hospital of a polyclinic, hospital at home, hospital day stay in the hospital, serves as the “Journal of admission of patients and refusals of hospitalization” (f. N 001/u). If a polyclinic (outpatient department) has several day hospitals and hospitals at home, then a log is kept in each of them.

Entries in the journal upon admission and discharge are made on the basis of the “Medical record of an outpatient patient” (f. N 025/u-87) or “History of the child’s development” (f. N 112/u). In a day hospital in a hospital, entries in the journal upon admission of a patient can be made on the basis of an “extract from medical card outpatient (inpatient) patient" (form N 027/u), if the patient was admitted for treatment from a clinic that is not united with this hospital. Entries in the journal when a patient is discharged from a day hospital are made on the basis of the "Medical record of an inpatient patient" (form . N 003/у).

In a day hospital of a polyclinic, a hospital at home, records about the patient’s condition when prescribing treatment, diagnostic tests, as well as generalized information about the treatment performed and its results are entered into the “Medical record of an outpatient patient” or “History of child development”, which are transferred to the hospital from the department who referred the patient for treatment.

In a day hospital in a hospital, all records are entered into the “Inpatient Medical Record”.

The medical record of an outpatient, the history of a child’s development, or the medical record of an inpatient indicates the number of days of treatment in a day hospital of a clinic, a hospital at home, or a day hospital in a hospital. The first day is considered to be the day of the beginning of medical and recreational activities, the last is the day of their end.

For each patient in a day hospital of a polyclinic, a hospital at home, a day hospital in a hospital, a “Patient Card of a day hospital of a polyclinic (hospital at home), a day hospital in a hospital” (f. N 003-2/u-88) is maintained.

The passport part of the card is filled out nurse upon admission of the patient. The attending physician writes down the prescriptions in the chart, diagnostic studies, procedures, therapeutic and recreational activities. The attending physician, medical specialists advising the patient, secondary medical workers Those carrying out doctors’ orders put the date of the examination (fulfillment of the appointments) and their signature.

The card is issued to the patient for the duration of their stay in a day hospital, hospital at home, or day hospital.

At the end of treatment, the attending physician takes the card from the patient, looks at it, clarifies previously made notes, and notes the outcome of treatment. The card is handed over to the accounting office and medical statistics an institution that organizes a day hospital, a hospital at home, a day hospital. The map is used to analyze the results of treatment and evaluate the activities of a day hospital, a hospital at home, or a day hospital.

(Upon completion of statistical development and after drawing up established annual reports by decision of the chief physician of the hospital (clinic), the cards can be destroyed or attached to other documents stored in the “Medical record of an outpatient,” “History of child development,” “Medical record of an inpatient.”)

Records of the work of a doctor working in a day hospital of a polyclinic or a hospital at home are kept on general principles according to the “Doctor’s Work Diary...” (f. N 039/u-87) by a nurse working with a doctor, based on entries in the medical record of an outpatient or the history of the child’s development.

When a patient is discharged from a day hospital in a hospital, the “Inpatient Medical Record” is archived. When transferring a patient according to indications to a hospital department for round-the-clock stay, it is necessary to register him as admitted in the “Register of admission of patients and refusals of hospitalization” of the hospital’s admission department. In this case, the “inpatient medical record” is transferred to the department where the patient is transferred. When a patient is discharged from the department, the “Inpatient Statistical Card” (form N 066/u) is filled out, in which the day of admission is considered the date the patient is transferred to the department for round-the-clock stay.

Note: depending on the specific situation To record the movement of patients in a day hospital in a hospital, it is allowed to use the “Sheet for recording the movement of patients and hospital beds” (form N 007/u).

List of documents maintained in day hospitals (hospital-based)

The main medical documents in the day hospital are:

- medical record of an inpatient (form 003-u);

- log of admission of patients and refusals of hospitalization (form 001-u);

- temperature sheet (form 004);

- list of medical prescriptions;

- book for issuing certificates of incapacity for work (form 036-u);

- card of the patient being treated in the office physical therapy(form 042-у);

- card of a patient being treated in a physiotherapy department (office) (form 044);

- journal of procedures (form 029-u);

- notice of side effect medicinal product(form 093-у);

- registration sheet for transfusion of transfusion media (form 005-u);

- log of registration of transfusion of transfusion media (form 009-u);

- recording log surgical interventions(form 008-у);

- statistical card of a person leaving the hospital (form 066);

- a sheet recording the movement of patients and hospital beds (form 007-u);

- logbook for sanitary education work (form 038-0-u).


AGREED
with the USSR Ministry of Health

Addition to the "List of forms of primary medical documentation of healthcare institutions", approved by order of the USSR Ministry of Health dated 10/04/80 N 1030

1. Include in the list of primary forms medical documentation

Form name			Document type	Shelf life
Patient's day card inpatient clinic, inpatient hospital at home, day hospital in hospital				determined by the head of the institution

Head of Department
medical statistics
Ministry of Health of the USSR
G.F. Tserkovny

Card of a patient in a day hospital of a polyclinic, hospital at home, day hospital in a hospital (underline)

Ministry of Health of the USSR		Medical documentation
Name of institution		form N 003-2/у-88
		Approved Ministry of Health of the USSR 04/08/88

MAP patient in a day hospital of a polyclinic, hospital at home, day hospital in a hospital (underline)

Full Name

Date of Birth

Home address

Place of work, occupation

start of treatment

graduation

Certificate of temporary incapacity for work

3. Diagnostic tests

Assigned (emphasize)

Done (date, signature)

Endoscopic examination

Ultrasonography

Copy (graphy)

Laboratory research

4. Surgical operations:

Operation name

the date of the

5. Treatment outcome (underline):

improvement, deterioration, no change, recovery.

Transfer to hospital.

Signature of the attending physician

1. Diary of observation and implementation of appointments

Appointments		Completion date and signature
	Examination by the attending physician
	Acupuncture

Electronic document text
prepared by Kodeks JSC and verified against:

"Medical editorial office "Chief Physician".,
Directory of the day hospital manager"
(List and Instructions);
forms (mailing

OKUD form code _______________

Institution code according to OKPO __________

Medical documentation

Form No. 003-2/у-88

Approved by the USSR Ministry of Health

04/08/88

Name of institution

MAP

patient in a day hospital of a polyclinic, hospital

at home, day hospital, hospital

(emphasize)

Full Name _______________________________________

Date of Birth ________________________________________________

Home address _______________________________________________

Place of work, occupation _____________________________________

Start of treatment _______________________________________________

Endings _____________________________________________________

Diagnosis ______________________________________________________________

______________________________________________________________

______________________________________________________________

______________________________________________________________

Certificate of temporary incapacity for work

From __________________________ to ______________________________

3. Diagnostic tests

______________________________________________________________

Nominated | Done

(underline) | (date, signature)

______________________________________________________________

ECG........................ |______________________________

Endoscopic |

Research............ |______________________________

Ultrasonic |

Research............... |______________________________

Copy (graphy) |

_______________________________|______________________________

Laboratory research |

Dovaniya................... |______________________________

|______________________________

_______________________________|______________________________

4. Surgical operations:

Operation name _________________________________________________

______________________________________________________________

The date of the ______________________________________________

5. Treatment outcome (underline):

Improvement, deterioration, no change, recovery.

Transfer to hospital.

"___"_________________ 19. Signature of the attending physician

1. Diary of observation and implementation of appointments

1. Examination by the attending physician

2. Massage...............

3. Exercise therapy...................

4. Acupuncture.........

5. _____________________

6. _____________________

7. _____________________

8. _____________________

9. _____________________

10. _____________________

11. _____________________

12. _____________________

13. _____________________

14. _____________________

INSTRUCTIONS

^ ABOUT THE PROCEDURE FOR RECORDING PATIENTS UNDER TREATMENT

IN DAY CARE POLYCLINICS, INPATIENTS

AT HOME AND DAY STAY IN HOSPITALS

This instruction is mandatory for all medical institutions of the USSR Ministry of Health system.

Validity period: from the moment of approval.

To register patients admitted for treatment in a day hospital of a polyclinic, a hospital at home, or a day hospital in a hospital, the “Register of admission of patients and refusals of hospitalization” (f. No. 001/u) is used. If a polyclinic (outpatient department) has several day hospitals and hospitals at home, then a log is kept in each of them.

Entries in the journal upon admission and discharge are made on the basis of the “Medical record of an outpatient patient” (form No. 025/u-87) or “History of the child’s development” (form No. 112/u). In a day hospital in a hospital, entries in the journal upon admission of a patient can be made on the basis of an “extract from the medical record of an outpatient (inpatient) patient” (form No. 027/u), if the patient was admitted for treatment from a clinic not united with this hospital . Entries in the journal when a patient is discharged from a day hospital are made on the basis of the “Medical record of an inpatient” (form No. 003/u).

In a day hospital of a polyclinic, a hospital at home, records about the patient’s condition when prescribing treatment, diagnostic tests, as well as generalized information about the treatment performed and its results are entered into the “Medical record of an outpatient patient” or “History of child development”, which are transferred to the hospital from the department who referred the patient for treatment.

In a day hospital in a hospital, all records are entered into the “Inpatient Medical Record”.

The medical record of an outpatient, the history of a child's development, or the medical record of an inpatient indicates the number of days of treatment in a day hospital of a clinic, a hospital at home, or a day hospital in a hospital. The first day is considered to be the day of the beginning of medical and recreational activities, the last is the day of their end.

For each patient in a day hospital of a polyclinic, a hospital at home, or a day hospital in a hospital, a “Card of a patient in a day hospital of a polyclinic (a hospital at home), a day hospital in a hospital” (f. No. 003-2/u-88) is maintained.

The passport part of the card is filled out by the nurse upon admission of the patient. In the card, the attending physician writes down appointments, diagnostic tests, procedures, medical and health measures. The attending physician, medical specialists advising the patient, paramedical workers carrying out doctors’ prescriptions, put the date of the examination (fulfillment of the prescriptions) and their signature.

The card is issued to the patient for the duration of their stay in a day hospital, hospital at home, or day hospital.

At the end of treatment, the attending physician takes the card from the patient, looks at it, clarifies previously made notes, and notes the outcome of treatment. The card is submitted to the accounting and medical statistics office of the institution that organizes a day hospital, a hospital at home, or a day hospital. The map is used to analyze the results of treatment and evaluate the activities of a day hospital, a hospital at home, or a day hospital.

(Upon completion of statistical development and after drawing up the established annual reports, by decision of the chief physician of the hospital (polyclinic), the cards can be destroyed or attached to other documents stored in the “Medical record of an outpatient”, “History of child development”, “Medical record of an inpatient” ).

Records of the work of a doctor working in a day hospital of a polyclinic, hospital at home, are kept on a general basis according to the “Doctor’s Work Diary...” (f. 039/u-87) by a nurse working with a doctor, based on entries in the outpatient medical record patient or child's developmental history.

When a patient is discharged from a day hospital in a hospital, the “Inpatient Medical Record” is archived. When transferring a patient according to indications to a hospital department for round-the-clock stay, it is necessary to register him as admitted in the “Register of admission of patients and refusals of hospitalization” of the hospital admission department. In this case, the “inpatient medical record” is transferred to the department where the patient was transferred. When a patient is discharged from the department, the “Inpatient Statistical Card” (form No. 066/u) is filled out, in which the day of admission is considered the date the patient is transferred to the department for round-the-clock stay.

Note: depending on the specific situation, to record the movement of patients in a day hospital in a hospital, it is allowed to use the “Sheet for recording the movement of patients and hospital beds” (form No. 007/u).

In order to unify approaches to filling out reports for day hospitals, I order:

1. Approve:

1.1. Instructions for filling out reporting form N 14ds “Information on the activities of day hospitals of a medical institution” (appendix).

2. Instructions for filling out reporting form No. 14ds “Information on the activities of day hospitals of a medical and preventive institution” will come into effect from 12/01/2003.

3. Entrust control over the implementation of this order to Deputy Minister R.A. Halfina.

Minister
Yu.L. SHEVCHENKO

Application

Application

INSTRUCTIONS FOR COMPLETING REPORTING FORM N 14DS "INFORMATION ON THE ACTIVITIES OF DAY STATIONS OF A TREATMENT AND PREVENTIVE INSTITUTION" (APPROVED BY ORDER OF THE MINISTRY OF HEALTH OF THE RUSSIA DATED 12/30/2002 N 413)

Column 3 “Number of beds” indicates the number of beds in a day hospital at the end of the reporting year for each bed profile (in accordance with the name of the bed profile approved by the Ministry of Health of Russia), deployed in a day hospital in accordance with the order of the head of the institution, taking into account the shift work of day hospitals.

Column 4 “Number of average annual places” shows information from the final line (“per year”) of form N 016/у-02, column 4 divided by 12.

Column 5 - “Patients admitted” is filled out based on the information in column 6 “Total patients admitted” (according to the final line “For the year”) of form N 016/u-02 for the corresponding bed profiles.

Column 6 - “Patients discharged” is filled out based on the information in column 12 “Total discharged” according to the final line “for the year” of form N 016/u-02.

Column 7 “of which children (0 - 17 years old)” is filled out on the basis of form 066/у-02.

Column 8 - "including 24-hour hospital". Information on the number of people discharged from a day hospital to a 24-hour hospital is highlighted from column 6 (from the number of discharged patients) and corresponds to the information in column 14 of form N 016/u-02 "incl. to a 24-hour hospital."

Note:

Patients sent from a day hospital to a 24-hour hospital, and vice versa, are considered discharged and admitted, respectively; two statistical exit cards are filled out for them, the same applies to admission and discharge within one institution. IN in this case It is allowed to keep one medical history, indicate the card number through a fraction: in the numerator - the number of the medical history of a 24-hour hospital, in the denominator - a day hospital.

Column 9 - “Days of treatment spent by patients.” Filled out on the basis of column 18 of the registration form f. N 016/у-02.

Note:

When calculating days of treatment, the day of admission and the day of discharge in a day hospital are counted as 2 days.

"Day hospital at outpatient clinics"

Columns 10 to 21 reflect information on day hospitals at outpatient clinics and hospitals at home. The information is filled out in accordance with the data in registration form N 007дс/у-02 (consolidated), except for columns 14 and 19, which are filled out on the basis of form N 066/у-02.

Column 10 - "Number of places." The number of places at the end of the reporting year is indicated based on f. N 007ds/u-02 (consolidated) column 3, taking into account the shift work of the day hospital.

Note:

When approving the work schedule of a day hospital in 2 shifts, the number of times when allocating places must take into account the number of shifts of work of the day hospital, i.e. 1st place is considered equivalent to 2nd places.

Column 11 - "Number of average annual places." The number of average annual places at the end of the reporting year is indicated based on f. N 007ds/u-02 (consolidated) column 4.

Column 12 - "Patients received." Filled out based on the information “Total patients admitted” f. N 007ds/u-02 (consolidated) column 6.

Column 13 - "Discharged". Filled out based on the information “Total patients discharged” f. N 007ds/u-02 (consolidated) columns 11.

Column 14 - “of which children.” Filled out according to the card of the person leaving the hospital f. N 066/у-02.

Column 15 "including 24-hour hospital." Information about discharged patients is shown, based on column 12 “including to a 24-hour hospital” f. N 007ds/u-02.

Column 16. - “Days of treatment spent by patients.” Filled out on the basis of column 17 “Days of treatment spent by patients” of form N 007ds/u-02 (consolidated).

Note: the day of admission and the day of discharge are counted as 2 days.

"Hospital at home"

Columns 17 - 21 are filled in based on f. 007ds/u-02 (consolidated).

Filled out in accordance with the same procedure as the section “day hospital for APU”. (columns 10, 13, 14 - 16).

Subtabular line 1101 shows information about the deceased:

In paragraph 1 "at hospital facility" - shows the number of deaths from the total line in column 16 of form N 016/у-02;

In paragraph 2 “at an outpatient clinic” - the number of deaths from the total line in column 13 of form N 007ds/u-02 (consolidated) is shown;

In paragraph 3 “for day care at home” - the number of deaths from the total line in column 13 of form N 007ds/u-02 (consolidated) is shown.

In subtabular line 1102 in paragraphs 1 - 3, “rural residents” are shown among those who left (discharged and died) from day hospitals, information is taken from f. N 066/у-02.

Section II. Composition of patients in the day hospital, terms and outcomes of treatment

The section shows information on the number of retired (discharged and deceased) sick adults 18 years of age and older (Table 2000) and children 0 - 17 years old (Table 2003) by disease class for all types of day hospitals, filled in according to statistical cards of those who left hospital (registration form N 066/у-02).

Table 2000 “Composition of patients in day hospitals, terms and outcomes of treatment” (18 years and older). In columns 1 and 3, lines 2 to 19 list the names of disease classes in accordance with ICD-10 codes. Line 1 - “Total” shows information on the sum of lines from 2 to 19 for all columns of the table; Line 20 shows information about persons who were also hospitalized for other reasons, in accordance with ICD-10 class XXI codes. Line 21 “Patients operated on” shows information about the number of patients operated on among those discharged and those who died, and line 22 shows the number of operations performed.

Column 4 shows information about the number of discharged patients, column 5 contains information (from among those discharged) about those sent to a 24-hour hospital.

Note:

Patients sent to a 24-hour hospital from a day hospital and vice versa are considered discharged and admitted. For such a patient, 2 statistical cards of the departed and (f. N 066/u-02) are filled out, as for a departed different types institutions. “Information about patients in a 24-hour hospital” is included in reporting form No. 14 “Information on the activities of a hospital,” and about patients in a day hospital - in form No. 14ds - “Information on the activities of day hospitals.”

Information in subtabular line 2002 “Persons hospitalized for examination and found to be healthy” is shown from line 20 “In addition, factors influencing the state of health of the population and visits to health care institutions” of table 2000 (table 2003 - from line 21).

The sum of lines 1 - "Total" and 20 - "In addition, factors influencing the state of health of the population and visits to health care institutions" in column 4 "Patients discharged" of table 2000 plus the sum of lines 1 - "Total" and 21st - “In addition, factors influencing the health status of the population and visits to health care institutions” in column 4 “Discharged patients” of table 2003 should be equal to the information shown in t. 1100, page 1, gr. 6 “discharged” .

A similar comparison is made with Table 1100 for the day hospital at the clinic (groups 8 - 11) and the hospital at home (groups 12 - 15).

Column 5 - “Of these, they were sent to a 24-hour hospital.” The sum of the 1st lines “Total” in column 5, tables 2000 and 2003 should be equal to the information in table 1100, page 1, column 8 - “including those sent to a 24-hour hospital.”

Column 7. “Died” (in a day hospital at a hospital institution), the number of deaths based on the sum of 1 rows - “Total” of tables 2000 and 2003 in column 7 should be equal to the number of deaths shown in subtabular line 1101 “Died in a day hospital at hospital institutions - clause 1".

Column 11 “Died” (in day hospitals with APU) - the number of deaths based on the sum of 1 rows - “Total” of tables 2000 and 2003 in column 11 should be equal to the number of deaths shown in subtabular line 1101 “Died in a day hospital with outpatient - polyclinic institution" - clause 2.

Column 15 “Died” (in a hospital at home) - the number of deaths based on the sum of 1 rows - “Total” of tables 2000 and 2003 in column 15 should be equal to the number of deaths shown in subtabular line 1101 “Died in a day hospital at home” - clause 3.

"Type of payment"

Table 4000. Information about types of payment is filled out on the basis of form N 066/у-02 - statistical map leaving the hospital.

In table 4000, columns 3 - 5 provide information on the number of retired patients (discharged and deceased), in columns 6 - 8 - information on the number of days of treatment spent by discharged patients for all types of day hospitals by type of payment: in line 1 - according to compulsory medical insurance, in the 2nd - according to the budget, in the 3rd - on a paid basis, in p. 4, incl. according to VHI (from line 3).

The number of days of treatment spent by discharged patients includes the days of treatment of both discharged and deceased patients, therefore the sum of the numbers in lines 1 + 2 + 3 in columns 6, 7, 8 (by type of hospital) must be equal to or greater than the numbers in the sum of lines 1 and 20 tab. 2000 and lines 1 and 21 tab. 2003 due to the days of treatment of the deceased.

According to the number of patients who left:

For day care at a hospital institution (column 3) - the sum of lines 1, 2, 3 should be equal to the sum of lines of the 1st and 20th tab. 2000 and 1st and 21st tab. 2003 according to columns - 4 (discharged) and 7 (died).

For day hospitals at an outpatient clinic - (column 4) - the sum of the numbers in lines 1, 2, 3 should be equal to the sum of lines of the 1st and 20th tables. 2000 and 1st and 21st tab. 2003 according to columns - 8 (discharged) and 11 (died).

A similar check is carried out for hospitals at home (according to the corresponding columns).

The Zakonbase website contains the ORDER of the Ministry of Health of the Russian Federation dated November 13, 2003 N 548 "ON APPROVAL OF INSTRUCTIONS FOR COMPLETING THE REPORTING FORM FOR DAY HOSPITAL CARE" in the most latest edition. It is easy to comply with all legal requirements if you read the relevant sections, chapters and articles of this document for 2014. To find the necessary legislative acts on a topic of interest, you should use convenient navigation or advanced search.

On the Zakonbase website you will find the ORDER of the Ministry of Health of the Russian Federation dated November 13, 2003 N 548 "ON APPROVAL OF INSTRUCTIONS FOR COMPLETING THE REPORTING FORM FOR DAY HOSPITAL CARE" in the latest and full version, in which all changes and amendments have been made. This guarantees the relevance and reliability of the information.

At the same time, you can download ORDER of the Ministry of Health of the Russian Federation dated November 13, 2003 N 548 “ON APPROVAL OF INSTRUCTIONS FOR FILLING OUT THE REPORTING FORM FOR DAY HOSPITAL CARE” completely free of charge, both in full and in separate chapters.

Answer: Maintaining a patient’s day hospital card in form N 003-2/u-88 does not exclude the obligation medical institution for maintaining a medical record of an inpatient according to form 003/u

Rationale:
As follows from the industry standard OST 91500.01.0005-2001 “Terms and definitions of the standardization system in healthcare”, introduced by the Order of the Ministry of Health of Russia dated January 22, 2001, medical documents are understood as special forms of documentation maintained medical personnel, which regulate actions related to the provision of medical services.
Medical documentation includes documents whose forms are contained in:
- List of forms of primary medical documentation of healthcare institutions, approved. By order of the USSR Ministry of Health of October 4, 1980 N 1030.
- Order of the Ministry of Health of Russia dated December 15, 2014 N 834n “On approval of unified forms of medical documentation used in medical organizations providing medical care V outpatient setting, and procedures for filling them out";
- Order of the Ministry of Health of Russia dated December 31, 2002 N 420 “On approval of forms of primary medical documentation for psychiatric and drug treatment institutions.”
So in accordance with the specified regulations, today medical documents include, in particular:
- medical record of an inpatient (form 003/у),
- medical record of a patient receiving medical care on an outpatient basis (form 025/у),
- medical record of an orthodontic patient (form 043/у),
- individual card pregnant woman and woman in labor (form 111/у),
- extract from the medical record of an outpatient, inpatient (form 027/u), etc.
According to the “Instructions on the procedure for registering patients undergoing treatment in day hospitals of polyclinics, hospitals at home and day hospitals in hospitals,” approved by Soyuzmedstatistika dated 04/08/88 N 27-14/4-88, for each patient in a day hospital of a polyclinic , a hospital at home, a day hospital in a hospital, a “Patient Card of a day hospital of a polyclinic (a hospital at home), a day hospital in a hospital” (f. N 003-2/u-88) is maintained.
At the same time, registration of patients admitted to these hospitals, “Log of admission of patients and refusals of hospitalization” (f. N 001/u).
Entries in the specified journal are made on the basis of:
On admission:
N 025/у-87)
- extracts from the medical record of an outpatient (inpatient) patient" (form N 027/u), if the patient was admitted for treatment from a clinic not affiliated with this hospital.
Upon discharge
- medical record of an outpatient (form N 025/u-87)
- medical record of an inpatient" (form N 003/у).
At the same time, today, instead of the excellent form of an outpatient medical record (form N 025/u-87), there is a “Medical record of a patient receiving medical care on an outpatient basis” (N 025/u). And it is carried out in accordance with the provisions of Order of the Ministry of Health of Russia N 834n dated December 15, 2014 “On approval of unified forms of medical documentation used in medical organizations providing medical care in outpatient settings, and procedures for filling them out”
This map is the main accounting medical document medical organization providing medical care on an outpatient basis to the adult population, and is filled out for each patient who seeks medical care on an outpatient basis for the first time (points 1 and the Procedure for filling out registration form N 025/u “Medical record of a patient receiving medical care on an outpatient basis” (Appendix N 1 to Order of the Ministry of Health of the Russian Federation dated December 15, 2014 N 834n).
Maintaining an outpatient card is carried out in accordance with the Order of the Ministry of Health and Social Development of Russia dated November 22, 2004 N 255 “On the Procedure for the provision of primary health care citizens eligible to receive the kit social services».
“Card of an inpatient patient”, “Extract from the medical record of an outpatient (inpatient) patient” and “Journal of admission of patients and refusals of hospitalization”, approved by Order of the USSR Ministry of Health N 1030 of 10/04/1980, are still maintained according to forms N 003/у, N 027/u and f. N 001/у, respectively.
According to the letter of the Ministry of Health and Social Development of the Russian Federation dated November 30, 2009 N 14-6/242888 “On the validity of the Order of the USSR Ministry of Health dated October 4, 1980 N 1030”, due to the fact that after the cancellation of the Order of the USSR Ministry of Health dated October 4, 1980 N 1030 “On approval of forms of primary medical documentation of healthcare institutions”, a new album of samples of accounting forms has not been published; healthcare institutions, on the recommendation of the Ministry of Health of Russia, are allowed to use in their work to record their activities forms approved by the above