"Methodological recommendations for organizing the workplace of a doctor and a nurse in a polyclinic." Requirements for organizing a nurse's workplace

Approved

Main Directorate

treatment and prophylactic

assistance from the USSR Ministry of Health

Agreed

Trade Union Central Committee

medical workers

ON ORGANIZING A DOCTOR'S WORKPLACE

AND THE NURSE OF THE POLYCLINIC

Methodological recommendations were prepared by employees of the Department of Medical Information for Workers of Healthcare Institutions of the All-Russian Research Institute of SG and Healthcare named after. N.A. Semashko (Yu.I. Zotov, G.I. Kutsenko, V.S. Vasyukova, D.K. Eremina, head of department, Doctor of Medical Sciences V.F. Minakov) and the council social insurance Central Committee of the Trade Union of Medical Workers (V.S. Shurupova, N.I. Kolesnik).

One of the important sections scientific organization labor (LOT) aimed at creating favorable conditions for effective and high-quality work, is the rational organization of the workplace and working conditions of medical personnel in outpatient clinics. However, to date, this issue has not yet received due attention in the country's clinics. Stationery tables used in the practice of doctors and nurses due to limited area coverings and lack of facilities for placing medical documentation, instruments and office equipment are of little use for establishing order in the workplace. Often at a doctor’s workplace you can find a mountain of medical records, different forms, directions, glasses with spatulas and thermometers, which creates crowding and chaos. Poor workplace organization leads to wasted working time. It has been established that during a three-hour outpatient appointment, a local general practitioner has to search for a lost medical document, form, or medical record on average four times. The time spent searching for each document ranges from 10 s to 3.5 m. In addition to lost working time, this circumstance causes additional psycho-emotional stress in the work of the doctor and nurse, creates an unfavorable atmosphere at the reception, and negatively affects the state of the diagnostic and treatment center. process.

Specially conducted studies have shown that many elements of a doctor’s work during an outpatient appointment are performed in forced, non-physiological positions, which leads to a rapid increase in fatigue of various parts of the musculoskeletal system, the development of functional insufficiency and discomfort in them, and also negatively affects the quality of diagnostic work, especially at the stage of physical examination of the patient. To a large extent, the forced working postures of medical workers at outpatient appointments is associated with the irrational organization of workplaces: imperfect equipment, incorrect selection and placement of furniture, its inconsistency with the specifics of work, anthropometric data and physiological capabilities of workers.

Improving the organization and maintenance of workplaces in health care institutions should be aimed at creating optimal conditions that ensure a high level of performance of medical personnel and a more complete use of the working time of doctors and nurses for basic types of work.

Experience rational organization labor of the country's leading institutions: polyclinic No. 22 in Kyiv, polyclinic No. 1 in Novopolotsk, a number of outpatient clinics in Riga, Dushanbe, outpatient department of the Aluksen Central District Hospital of the Latvian SSR, etc. and results scientific research, carried out by the NOT Department of the All-Russian Research Institute of SG and OZ named after. N.A. Semashko, made it possible to identify the basic requirements and outline measures to improve the organization of workplaces for doctors and nurses conducting outpatient visits.

General requirements for workplace organization

The workplace should be understood as the area of labor activity of an employee or group of employees, equipped and equipped with everything necessary to perform their official duties. When organizing workplaces for medical workers, the type of institution and the profile of the specialist are first taken into account, that is workplace must be specialized.

The rational organization of any workplace in a medical institution must include equipment, rational layout, organization of workplace maintenance, compliance with ergonomic, aesthetic and sanitary-hygienic requirements.

Equipping workplaces is one of the main conditions for the rational use of labor of medical workers and involves providing each workplace with a set of furniture, special instruments and equipment, office equipment, standard forms, etc. When equipping, it is necessary to take into account the nature labor activity working.

The rational placement of medical furniture and equipment in the doctor’s office is important in organizing the workplace. In accordance with ergonomic requirements (see below), as well as based on observations of the actions of the doctor and nurse, it is recommended that the furniture and equipment of the doctor’s office be placed in accordance with the following rules:

The doctor's and nurse's desk should be in the most illuminated part of the office;

There must be space around the table that allows free movement of the doctor and nurse from the table to any object in the office;

The couch for examining the patient should be positioned so that the right half of the patient’s body is on the doctor’s side; the couch must be fenced off from front door use a screen and place a chair close to it for the patient;

The location of each item must be thought out in order to minimize the cost of movement and ensure compliance with aesthetic requirements in the design of the office;

The office door must be visible so that the doctor can see the patient entering.

Ergonomic requirements for the organization of workplaces determine the compliance of the design data and dimensions of work furniture and organizational equipment with the anthropometric, biomechanical and psychophysiological capabilities of the human body. Compliance with them makes it possible to provide a medical worker with a physiologically rational posture during work that meets the criteria of functional comfort.

Hygienic requirements for the organization of workplaces in medical offices provide for compliance with basic sanitary and hygienic standards: sufficient area, cubic capacity, footage per worker, microclimate parameters, lighting, noise, etc.

Aesthetic requirements for the organization of workplaces provide for the implementation of a set of recommendations for the artistic design of work premises, office interiors, and the institution as a whole.

Ergonomic, hygienic and aesthetic requirements for the organization of workplaces are set out in the relevant regulatory and methodological materials.

Maintenance of workplaces includes organizing document flow, providing medications, standard forms and instruments, organizing sick calls, preparing workplaces and cleaning premises. IN recent years In many medical institutions, centralized provision of workplaces with everything necessary has become widespread.

In the rational organization of workplace services, an important place should be given to the use of standard forms for referrals for research and treatment. As observations have shown, the frequency of referrals, for example, in the office of a local general practitioner is on average 23 times by a doctor and 46 times by a nurse per 100 visits, and in an ENT office - 21 and 31, respectively. An average of 1.4 m is spent on issuing one referral. Taking into account the fact that the patient needs to be explained where and in which office he needs to appear, how to prepare for the study, the unproductive expenditure of working time increases significantly. Therefore, the rationalization of this element of the work of medical personnel has a significant benefit in the work of clinic specialists. It is recommended to use standard referral forms for certain types of research (Appendix 2 - not provided). The front side of each referral form consists of two sections. In the first section, the nurse enters the patient's last name, initials, medical card number and address, as well as the doctor's last name and date of appointment. The second part is intended to fill out the results of the study of auxiliary diagnostic services. The reverse side of the form has a memo for the patient, including information about the rules of preparation for the study, the place and time of its conduct. The presence of such forms completely frees the doctor from writing directions and saves working hours nurses. Referral forms must be placed in the table's blank file, only in this case they are convenient to use.

The use of pre-prepared prescriptions significantly saves a doctor’s working time. It has been established that the frequency of their discharge is, for example, an average of 100 - 150 per 100 visits for an otolaryngologist, and 200 - 250 for a local general practitioner, respectively. Specially conducted studies have shown that an otolaryngologist operates on approximately 100, and local doctor 140 - 160 prescriptions, most of which are used repeatedly during the working day and week. Taking into account the above, the optimal volume of the prescription library should be designed for 40 - 60 prescriptions.

With a rational organization of the workplace, the issues of reducing the time spent on maintaining a medical record of an outpatient patient, which occupy at least 25 - 30% of the working time at the reception in the work of doctors of main specialties, require solutions. For this purpose, it is currently recommended in clinics to use cliché inserts in the medical record (developed at the N.A. Semashko All-Russian Research Institute of SG and Healthcare), which allows, by emphasizing the signs listed in them and entering the missing ones in specially designated lines, to significantly reduce (by 15 - 20%) costs for doctors to fill out a medical card. Samples of such inserts for a local general practitioner and an otolaryngologist are given in Appendix 3 (not provided). Inserts can be printed by printing or by making a rubber cliche. In the latter case, they are printed as needed directly in the doctor's office.

Maintaining functional connections between doctors at outpatient appointments is ensured by equipping workplaces with means of communication with all the main departments and services of the clinic: the registry, the offices of specialist doctors, the head of the department, and auxiliary treatment and diagnostic rooms.

To call a patient to the doctor’s office, it is advisable to use a light or sound alarm. When using a light alarm, a light sign is installed at the door of the office with the inscription “Do not enter”, which is illuminated while receiving a patient, and “Enter” when the doctor has received the patient and is calling the next one. In this case, the doctor’s workplace is equipped with a light signal switch. In the second option, any intercom communication device operating in loud-speaking mode is used (for example, PU-1).

Thus, thoughtful organization and maintenance of the workplace, its equipment and equipment taking into account the requirements of ergonomics and aesthetics, rational layout of the office should be aimed at creating conditions for effective and high-quality work of a doctor and nurse conducting outpatient visits.

Organization of the workplace of a local physician-therapist

For a doctor conducting an outpatient consultation, his desk is his workplace. Currently, taking into account the disadvantages associated with the use of conventional office tables in the work of local therapists, a number of functional tables have been proposed.

The outpatient doctor’s work desk, designed by P.E., has proven itself well. Beilin, which is used in clinic N 22 in Kyiv. It consists of four rectangular boards, three of which are vertical, installed in an H-shape, the fourth covers them horizontally. Equipment: a tape recorder, a microphone, a Riva-Rocci apparatus, glasses with spatulas and thermometers are “recessed” into the table cover, and glasses with disinfectants for storing thermometers and spatulas are also placed. Medical supplies are placed on the table in designated work areas. The table is equipped with a portable recipe library for 24 cassettes, mounted in the front drawer of the table. A folding board is provided to organize the nurse's workplace. The table can be recommended for use in clinics that have implemented a tape recording method for recording medical records.

The Republican Center for Medical Information Technology and the Health Department of the Ministry of Health of the Latvian SSR have proposed a unified table for a local physician, which is used in a number of clinics in Riga. On the horizontal plane of the table there is a recess for a tonometer, secured with a special bracket. The tabletop drawers contain directions for examinations and treatment, personal items for doctors and nurses. The top drawer of the table base is intended for short-term placement of medical records of outpatients. Delivery of medical records to the doctor’s office is carried out using containers, which are stocked at the reception desk in the order in which patients are seen by the doctor. Desktop file cabinets for A-5 format cards, produced by industry, are used as containers. The bottom drawer of the support cabinet of the specified table is intended for the personal belongings of the doctor and nurse. This table is recommended to be implemented in the work of a local general practitioner, whose work organization involves the use of standard directions for examinations and treatment, delivery of medical records in special containers.

Department of Notifications for Workers of Healthcare Institutions of the All-Russian Research Institute of SG and Healthcare named after. N.A. Semashko together with the All-Union Design and Engineering Institute of Technology The furniture includes a doctor's and nurse's desk, which uses printed inserts for medical records, standard referral forms, and pre-made prescriptions. The table has a slightly larger working surface (1280 x 940 mm) compared to a regular office desk. This allows you to organize a workplace for a doctor and a nurse at one table. Under the table cover, along the middle line on both sides, there are two flat drawers measuring 198 x 512 x 60 mm, designed to accommodate reference literature, site passports, and office supplies. The surface of the table has two zones - for the doctor and the nurse; in addition to the table there is a filing cabinet in the form of two bedside tables on wheels. Drawers in bedside tables act as containers for placing inserts of medical records, standard directions, registration forms, temporary storage of medical records, placement of control charts of dispensary patients, etc. The drawers of the bedside tables are pulled out using hanging hinges, which allow you to hold the extended containers in a horizontal position for the entire length. The presence of a separate form-card file allows you to install it in a place convenient for the doctor and nurse. There is a special device on the table surface for attaching the tonometer.

Aesthetic and hygienic requirements for the design of a local therapist's office are established in accordance with SNiP II-69-78 "Medical and preventive institutions. Design standards", according to which the area of the office should be 12 - 16 square meters. m (with a room width of at least 2.4 m and a depth of 4 - 6 m in conditions of one-sided lighting). The ratio of the depth of the room to its width should be no more than two.

The coloring of walls can influence the perception of the color of pathological tissues, emphasizing or, conversely, masking their pallor, cyanosis, etc. In this regard, it is preferable to paint the walls of the room in neutral colors, for example, light gray. The ceiling is painted in white, the floor is dark. It is advisable to have curtains on the windows in yellowish shades, and desk coverings in a green range of colors.

The optimal air temperature in the office according to GOST 12.1.005-76 "Air of the working area. General sanitary and hygienic requirements" in cold and transition periods of the year should be within 20 - 23 ° C, in the warm period of the year - 20 - 25 ° C at relative humidity 60 - 40% and air speed no more than 0.2 m/s in all periods of the year. To avoid violation thermal equilibrium and cooling of patients during physical examination, it is necessary that the difference in air temperatures horizontally (from the external walls to any point inside the room) and vertically (between the floor and a height of 1.5 - 2 m) does not exceed 1 - 2 °C. The frequency of air exchange in the office at least 1 time per hour is ensured by the use of natural ventilation.

According to GOST 12.1.003-76 “Noise. General safety requirements,” the noise level in offices should not exceed 30 dB, and in rooms for receiving patients in noisy industries, noise levels should not exceed 50 dB.

Bacterial contamination of the air in working areas should be no higher than 4000 per cubic meter. m of bacteria and 50 colonies per cubic meter. m representatives of hemolytic microflora.

The hygienic regime of the premises provides for wet cleaning twice a day.

The nature of the work of community therapists requires high levels of both natural and artificial lighting. At the same time, according to SNiP II-4-79 “Natural and artificial lighting. Design standards”, the normalized values of the coefficient of natural lighting (KEL) are 1.5 - 2.0; artificial illumination at the level of the table surface must be at least 300 lux and is provided by general lighting. Considering the high requirements for color discrimination in the work of a local therapist, preference should be given as a light source fluorescent lamps with optimal color characteristics. For lighting offices, lamps such as LHE, LDTs can be used.

In order to create an aesthetically pleasing workplace in the office of a local general practitioner, it is necessary to provide landscaping, which also acts as a factor that improves the microclimate.

Organization of a workplace for an otolaryngologist

The office of an otolaryngologist in accordance with SNiP II-69-78 is organized in a room with an area of 18 square meters. m, having at least 6 m in length, which is necessary for studying hearing in patients with whispering and colloquial speech. For the same purposes, good sound insulation should be provided when constructing the cabinet. It is recommended to place the ENT office in two adjacent rooms, one of which is intended for receiving patients, the other for complex manipulations and outpatient operations. New projects of outpatient clinics for 750 or more visits per day provide an operating room with a preoperative area of 22 square meters next to the otolaryngology office. m (14 sq. m + 8 sq. m).

The optimal air temperature in the ENT office is 18 - 20 °C, in the warm season - up to 25 °C. The frequency of air exchange is once per hour. If washing and drying surgical instruments are carried out directly in the workroom, the air exchange rate should be increased by three times the exhaust per hour. If there is a fume hood in the office in which work with biologically active drugs is carried out, optimal air conditions in the office can be ensured by natural ventilation.

Other hygienic indicators of the air environment correspond to the normative standards for the offices of local general practitioners.

One of the unfavorable factors in the working conditions of otolaryngologists is widespread contact with infection, which is confirmed by high level morbidity of specialists of this professional group with acute respiratory diseases identified during a special study. Taking into account this circumstance, special attention should be paid to measures aimed at reducing bacterial contamination in work areas.

The surface of walls and ceilings must be smooth, allowing wet cleaning and disinfection. The floor must be covered with a waterproof material that is easy to clean and can be frequently treated with a disinfectant solution.

It is more effective to sanitize air directly in the presence of people. For this purpose, the method of air disinfection with bactericidal lamps should be used. The domestic industry produces a wall-mounted bactericidal irradiator NBO, consisting of two lamps (BUV-30P): the upper (shielded) one irradiates the upper zone of the room in the presence of people, then the disinfected air flows through convection currents into the breathing zone of personnel and patients; the lower (open lamp) produces a short powerful irradiation in the absence of people for 15 - 20 m. Irradiation of the room with it after wet cleaning (before starting work and during the break between shifts) ensures death pathogenic microflora, which plays an important role in the etiology of acute and chronic diseases of the upper respiratory tract. When using UV rays for disinfection, the walls and ceiling of the room should be painted with yellowish oil paint that has an optimal reflection coefficient for ultraviolet rays.

When organizing the workplace of an ENT doctor and nurse, the use of ergonomically sound furniture is of great importance. According to a special study, otolaryngologists at outpatient appointments in the current working conditions spend more than half of their working time in forced positions. The non-physiological postures of otolaryngologists are primarily due to the specifics of the diagnostic and treatment process of persons in this specialty. The main elements of labor activity when examining patients and performing medical manipulations are carried out with non-fixed hands while tilting the body forward by 17 - 25°. This causes tension in the muscles of the back, upper shoulder girdle and is a significant load for the anterior sections of the cervical and thoracic vertebrae. Large service spaces (reach zone up to 1200 mm) force the doctor to make a significant number of forward and side bends (about 450 - 500) during one appointment. The situation is aggravated by the irrational organization of the workplace, which leads to rapid fatigue of various parts of the musculoskeletal system that bear the main load in these positions. This is confirmed by numerous complaints, as well as indicators of the state of the cardiovascular and muscular systems.

A feature of the work of persons in this specialty is the shortage motor activity: the dynamic component in the work of an otolaryngologist is only 4.7% of the working time. In these conditions, much attention should be paid to the rational organization of the working posture of the doctor and nurse in the ENT office. To do this, medical office staff must be provided with functional chairs. Since the otolaryngologist almost never leaves his workplace, the design of the work chair must provide conditions for short-term rest (maintaining the doctor’s body in a physiologically rational position while maintaining the natural curves of the spine, rest for the arms), for which the chair must be equipped with a backrest with armrests.

The otolaryngologist's chair must be movable in the horizontal plane with the possibility of automatically fixing it in in the right position. Rotation of the chair around the vertical axis of the supporting structure by 180° allows you to bring the size of the reach zones closer to optimal values. The mobility of the posture is also ensured by a flat semi-soft seat, covered with a softened, water-repellent, non-electrifying and airtight material. Of the work furniture produced by the domestic industry, the chair designed by the Volgograd Medical Equipment Plant meets these requirements to the greatest extent.

A rationally organized workplace for an otolaryngologist at an outpatient appointment includes a table for instruments (suggested by doctor A. Heeger) and a functional work desk. The instrument table is located to the left of the doctor. It provides the otolaryngologist with a comfortable posture during examination and treatment procedures. The table area, 1000 x 600 mm, allows you to rationally place all the necessary items and tools and install a work lamp at the required distance. The presence of another working area of the table, located below and parallel to the main one, allows you to timely free the working area from used tools.

It is advisable to use the functional table described in the previous section as an otolaryngologist’s work desk. The nurse’s workplace in this case is located at the same table, opposite the doctor. At some distance from the doctor’s and nurse’s workplace there is a table for instruments. This allows the nurse to actively assist the doctor in carrying out therapeutic and diagnostic procedures, as well as perform a number of independent manipulations prescribed by the doctor. As a result, the efficiency and volume of work of the ENT office increases.

The patient's chair should be rotating with headrests, which allows the head to be fixed when performing manipulations and outpatient operations.

The specific work of an otolaryngologist requires a certain degree of darkening of the office, which leads to contrasts in the illumination of objects in the surrounding space. At the same time, during otoscopy, laryngoscopy, and surgical interventions, the doctor has to deal with the small size of the observed objects, which necessitates bright illumination of the field of view. The frequent re-adaptation of the visual organ that occurs in these cases leads to a decrease in visual performance, the rapid development of fatigue, and with prolonged exposure - to pathological changes in the visual organ. Taking into account the above, special attention should be paid to rational lighting of the workplace. In order to provide favorable conditions for re-adaptation of the eye, the ratio of brightness levels of the workplace and the surrounding background should not exceed 1:3. To comply with this requirement, the walls and floor of the ENT office should be painted in light colors with a high reflectivity. For more uniform illumination and to eliminate glare caused by sunlight, the orientation of the ENT office is preferable to the north. For protection against direct and reflected sunlight It is necessary to have sun-protection devices on the windows (for example, blinds) that allow you to create the required degree of darkness in the office.

The required levels of illumination in the ENT office are created using a combined lighting system. On the surface of the desk, the illumination should be at least 300 lux. The illumination of the viewing area when examining a patient is created by light reflected from the working lamp, which is located at a distance of 10 - 15 cm from the patient and 60 - 70 cm from the doctor. As a light source in a work lamp, it is recommended to use 60 W incandescent lamps in a bulb made of milky (frosted) glass, which does not have a pronounced glare effect on the organ of vision. Incandescent lamps of this power provide an illumination level of 700 - 750 lux sufficient for examining ENT organs. Lamps attached with a bracket or mounted in the patient’s chair are convenient to use.

Important importance in organizing the workplace of an otolaryngologist and a nurse should be given to the layout of the office with the rational placement of furniture, necessary items and means of labor of the medical staff of the ENT office, taking into account ergonomic requirements, the separation of areas of activity of the doctor, nurse and the flow of visitors.

The rational organization of workplaces for doctors and nursing staff in outpatient clinics is based on knowledge of the specifics of the labor process, as well as compliance with hygienic, psychophysiological and ergonomic requirements for the working areas and working conditions of each specialist. The selection of functional furniture, the correct distribution of labor items and organizational equipment in the workspace, the use of rational forms and methods of organizing work allows you to avoid clutter and disorder in the workplace, eliminates unproductive waste of working time, and reduces the increase in fatigue. Only the comprehensive implementation of all the described measures makes it possible to create the necessary conditions for the effective and high-quality work of medical personnel in medical institutions.

The association assists in providing services in the sale of timber: at competitive prices on an ongoing basis. Forest products of excellent quality.

Problem correct acceptance and maintaining a working posture depends not only on the optimal choice of working position, but also on all surrounding objects and auxiliary devices: operator and assistant unit, hanging table with tools, placement of cabinets and sections. The location of all these items is of great importance.

It is important how far they are and at what height they are from the operator, what is their design and placement. After all, it is far from indifferent whether our movements are comfortable or inconvenient during work, since during the working day they represent a significant load on the operator’s body. During the working day, a doctor, in a cramped space, without taking into account other possible movements and movements, performs work that is equal in energy consumption to passing a section of road 4 km long. Even if this figure is only approximate, it is sufficiently convincing that we should travel this path as easily and naturally as possible. The central point in organizing the workplace should be considered the unit of the operator and his assistant. They must be mobile and placed at a convenient distance and height from the operator and assistant, and allow for easy work without stretching or bending. The optimal distance for placing the operator unit and the hanging table with tools is the distance at arm's length for each individual operator. Depending on the location of the doctor’s unit, the following systems of dental units are distinguished: S, T, C and G-systems. Considering the fact that the twelve o'clock position for working procedures is the most optimal for the doctor and assistant, cabinet-like sections should be located at the 12 o'clock position and in close proximity to the doctor and his assistant (arm's length distance). A clear example A well-thought-out organization of a dentist's workplace is the "Banana" system, proposed by Dr. Grimm and the company "Haubi" (Switzerland). The idea behind the banana shaped operating area was that if the dentist was sitting at any of the 8 o'clock and 12 o'clock positions relative to the patient's head, it would be desirable to have all the distances from the operating area (patient's head) to the office elements the same.

The principle of maintaining equal distances was implemented, the essence of which is that the doctor’s unit, the hanging table with the instrument and the auxiliary equipment are at the same distance from the operator; The patient's chair is located centrally and can be rotated.

Requirements for modern dental units

The convenience of the dentist’s work is ensured by the dental unit, which is the main element of the office equipment and should facilitate the use of modern dental treatment technologies.

The basic requirements for modern dental complexes are as follows:

Dental units must be powered by compressed air, purified from mechanical and chemical impurities, as well as drip moisture. The use of an oil compressor does not exclude the possibility of contamination of the surgical field with oil particles, which disrupts the polymerization process of composite materials and leads to premature loss of fillings;

the presence of an aspiration system (saliva ejector and vacuum cleaner) to remove aerosol and dust that are formed during the preparation of a carious cavity. In addition, the patient’s movements to the spittoon, which take up to 15% of the working time, are eliminated;

equipped with a turbine handpiece (with a bur rotation speed of at least 300,000 rpm and water-air cooling of the tooth processing area);

equipped with a micromotor and endodontic handpiece (sometimes the functions of the endodontic handpiece are performed by a micromotor equipped with reverse and adjustment of the rotation speed of the instrument).

The configuration of modern installations varies, and may include various types and number of tips, photopolymerizer, ultrasonic or piezoelectric scaler, but maximum quantity modules should not exceed seven, depending on the requirements of the doctor and the economic capabilities of the clinic.

The design of the dental chair should allow the doctor to work while sitting with the patient lying in the chair. The contour of the seat and backrest should provide the maximum possible support for the patient, ensuring anatomical conformity to his body and relaxation during manipulations. The thin back of the chair will allow the doctor to move as close to the patient as possible. The back support should not be very long, have maximum width in the area of the shoulder blades, tapering significantly downwards, reliably support the spine. The armrests should either be easy to move from horizontal to vertical positions, or removable and not be long. The headrest, having a wide range of movements, must be easily and securely fixed. A mechanism for changing the tilt of the headrest, independent of the position of the back, is required.

Changes in the position of the chair (raising, lowering, changing the reclining angle of the chair, etc.) should be carried out both from the operator’s and assistant’s seats. In this case, foot (pedal) control is preferable from the point of view of compliance with sanitary and epidemiological regulations.

The materials from which the chair is made must withstand mandatory repeated treatments with antiseptics and disinfectants. A color scheme of delicate tones is desirable.

The doctor's and assistant's chairs should be light and movable, with adjustable product height and backrest angle.

The doctor's hanging table - "UNIT" (block) should be mobile and located at arm's length, and the order of arrangement of instruments is determined by the order and frequency of their use.

Depending on the location of the "UNIT" modules, the installations are:

· T-type, "Dentsan", "Practic" (Chirana), "Ergostart 92 C" (Chirana), "Performer", "ADEC" (ADEC), "Cavo Systematica 1060 TK" (Cavo), "Fimer F1 Continental A" (Finland), "PM 2002 CC" (Planmeca OY), "BelDent" (Belarus), "Biotec CM 6-120" (Belarus), "Sirona M1", "Spirit S1" (Siemens), when the modules are on "Unit" are located vertically;

· S-type, "Quint 7000", "FD-5000 Comfort" (Finndent), "Fimet F1 Continental E" (Finland), "ADEC international, Model 2080" (ADEC), "Cavo Systematica 1060 SK" (Cavo) , "Promatic 1075 S" (Cavo), "Unident 1001" (JUGODENT), "Castellini" when the modules are positioned horizontally;

· G-type, "Promatic 1075 G" (Cavo) modules are mounted in the table, this is a stationary installation;

· C-type, "Cavo Junior" (Cavo), "Fimet F1 Cart" (Finland), "Unident 1002" (JUGODENT), "Ergostar 90 SU" (Chirana), mobile unit with "Unit" operator.

In recent years, the production of domestically produced dental complexes "Beldent" has begun. Dental units of economical, middle and high classes have been created.

Economical class dental complexes are equipped with the minimum necessary set of equipment, tools and accessories that are used to carry out basic therapeutic and orthopedic operations.

The economy class complex includes:

patient chair;

a mounted dental unit consisting of blocks of handpiece holders (three-function turbine handpiece, gun and micromotor);

dental compressor;

doctor's chair.

The middle-class dental complex differs from the one described above in that its design, in addition to the existing turbine handpiece and micromotor, includes a handpiece for removing dental plaque. In addition, the dental compressor includes a dental polymerizer, a glasperlene sterilizer and an ultrasonic washer for sterilizing instruments.

A high (business) class dental complex includes, in addition to the set of economical and middle class dental complexes:

a) turbine handpiece with illumination of the tooth treatment area (fiber optics) and with push-button bur fixation;

b) table for tools;

c) aspiration system;

d) mounted X-ray unit.

Ergonomics- a complex scientific discipline that studies the functional state of a person’s capabilities in labor processes in order to create optimal working conditions for him. Economics is closely related to psychology, physiology, and science, and uses data from anatomy, toxicology, and technical sciences.

Problems of Erronomics

Ensuring maximum convenience for the doctor’s work

Proper organization of the workplace and rational placement of equipment.

Ensuring comfortable air climate, lighting, combating noise and vibration.

Reducing the psychological and emotional stress on the doctor, ensuring the safety of working with the technical equipment of the office.

Reducing the physiological burden on the doctor by properly organizing the workplace, choosing comfortable postures and rational working movements, maximizing simplification of medical documentation.

Proper organization of work and rest regimes, development of methods for preventing occupational diseases.

Development of methods for working with personnel, advanced training of doctors and nursing staff.

Basic equipment of the therapeutic room (dental units, handpieces: types and principles of operation, care, main malfunctions)

A dental unit is a set of equipment designed to perform dental tasks.

To provide qualified care, the most important equipment is the dental unit. Dental unit is a hardware complex that allows you to perform basic dental interventions.

Currently, the concept of installation means a complete set that includes the installation itself, a chair, a compressor, a doctor’s table, a doctor’s chair and an assistant’s chair.

Dental unit device

The dental unit consists of functional blocks, each of which has its own purpose. Depending on the installation configuration, the set of blocks may vary.

Main blocks of the dental unit

- Tool block The main block of the dental unit contains instruments for manipulations in the oral cavity. Can be equipped with a lighting unit for instruments with fiber-optic illuminators.

- Low speed motors provide rotation speed of the rotary tool from 10,000 to 30,000 rpm.

-High speed rotary(turbine) tools provide rotary tool speeds ranging from 300,000 to 500,000 rpm. Usually there are two tips: therapeutic and orthopedic.

- Other tools scaler (tool for removing dental plaque), polymerization lamp (for polymerization of photopolymers), etc.

- Control unit consists of a pedal and a control panel, used to control all installation systems (chair position, tool rotation speed and other parameters).

- Hydroblock.

- Spittoon designed for disposal of saliva and other liquids into the sewer system, equipped with a flushing system.

- Glass shell Designed for filling a glass with water for rinsing the mouth. Equipped with a filter to purify incoming water.

- Saliva ejector designed for disposal of saliva and other liquids directly from the patient’s mouth into the sewer system.

- Vacuum cleaner designed for disposal of the aerosol mixture formed in the oral cavity when working with high-speed (turbine) handpieces.

- Water-air gun designed for drying with a stream of air and irrigating the oral cavity with water or an air mixture.

- Lighting block consists of a halogen lighting lamp for illuminating the working area and a bracket that allows you to raise, lower, rotate in a horizontal plane and hold the lamp in a given position.

- Dental chair designed to accommodate the patient. Moves in a vertical plane (raises and lowers) to provide a height convenient for

doctor's work.

- Compressor designed to supply compressed air to turbine tips and water-air gun.
Straight tip Designed for use with straight handpiece burs. They perform therapeutic manipulations mainly on the front teeth, orthopedic and orthodontic work. The straight handpiece is widely used in dental surgery and dental prosthetic laboratories.

Contra-angle handpiece Designed for use with burs, for contra-angle handpieces. They perform most therapeutic manipulations.

Turbine tip designed for securing cutting instruments and transmitting them Rotation with a frequency of 300,000-500,000 rpm when carrying out extensive therapeutic and orthopedic work (tooth trepanation, crown preparation).

Handpiece care

Handpiece care includes daily lubrication. For this purpose, a special lubricant is proposed: transformer, machine or other neutral oil is mixed with heated medical petroleum jelly in a ratio of 1:3 and cooled. Most often, lubricants are produced in aerosol packaging. In turbine tips, lubrication is carried out through the air supply channel, and in mechanical ones according to the instructions. The outer surface of the tip is treated with a 1% chloramine solution twice using two gauze pads for 30 minutes.

Basic malfunctions.

During operation, the following tip malfunctions may occur.

In direct vibration of the bur, weak fixation of the latter in the tip or slow, inhibited rotation. Bur falling out or stopping under heavy load during

operating time is the result of wear or breakage of the collet. In this case, replace the parts or, if worn, insert a spare washer between the clamping pin and the pressure sleeve.

Compared to a straight handpiece, a contra-angle handpiece fails faster and more often, causing the bur to vibrate, the end of the latch often breaks off, and the bur is not fixed in the handpiece. Its most common damage includes: braking of rotating parts as a result of thickening of lubricant and rust, wear of gear teeth, and loss of boron.

10. Dental instruments. Functional value (burs, endo.instruments, medicinal)

Dental instruments are intended:

1. For the preparation of hard tooth tissues.

2. Treatments.

3. Endodontic instruments.

Dental burs are used to prepare hard dental tissues.

The sizes of burs are distinguished by numbers: No. 1-0.85 mm: No. 3-1.1 mm; No. 5-1.6 mm; No. 7 – 2 mm; No. 9-2.7 mm; No. 13-3.1 mm.

The length of the burs for the straight handpiece is 44 mm, for the angled handpiece - 22 mm and 27 mm.

Therapeutic instruments are conventionally divided into: for examination of the oral cavity and filling, for removing dental plaque.

Therapeutic instruments are conventionally divided: for examining the oral cavity and filling, for removing dental plaque. Instruments for examination: – mirror (for examining the mucous membrane of the oral cavity, retracting the cheeks, lips, tongue, examining teeth, carious cavities and illuminating them); – tweezers (for inserting cotton swabs, medicinal substances); – a straight or angular probe (for examining fissures, dental caries, the location of canal mouths, overhanging edges of fillings, the presence of softened dentin, examining the depth of the periodontal pocket, the presence of tartar, etc.).

Endodontic instruments are divided into the following groups:

1. Instruments for widening the root canal orifice: Gates Glidden, Largo. Gates Glidden - has a small working surface on a long thin shaft, so it is designed to widen the mouth and upper third of the canal. A series of 6 (1-6) sizes is produced with sections 050, 070, 090, 110, 130, 150, 170. Largo - characterized by a large working surface, which allows them to be used for passing the canals of single-rooted teeth, as well as the palatal canal of upper molars and distal canals of lower molars. A series of 6 sizes is available with sections 070, 090, 110, 130, 150, 170.

2. Root canal instruments: K-Reamer, K-Flexoreamer, K-Fiexoreamer Golden medium and K-Nitiflex.

To traverse the length of root canals, a tool called a Reamer is used. Depending on the curvature and thickness of the channels, the following types of reamer are used:

K-Reamer – available in 20 sizes in accordance with ISO standards (08-140);

K-Flexoreamer is flexible, allowing it to be used in thin and curved canals. Available in a series of 6 sizes (15-40);

K-Flexoreamer Golden medium is an intermediate size tool, which is used in cases where difficulties arise when moving from one tool size to the next. Available in a series of 6 sizes (12-37).

When working with reamers, it is necessary to make movements similar to the movement when winding a watch.

3. Tools for expansion and alignment of channels:

K-File, K-FlexoFile – flexible canal expanders (drills) are used to widen canals with significant curvature. A series of 6 sizes is available (015-040);

K-File Golden Medium is a flexible channel dilator of intermediate sizes that makes it easier to transition from one size to the next. A series of 6 sizes is available (012-037).

When working with files, it is necessary to make reciprocating movements, not rotational ones.

Hedstroem File - root auger - a tool for leveling root canals.

When leveling channels with these tools, only translational movements are allowed, since if you try to rotate the axis, the tool may break off in the channel. The selected Hedstroem File must be one size smaller than the previously used file.

4. Tools for filling root canals:

– instruments for introducing endodontic pastes and root sealants into the canal – Lentulo canal fillers;

– tools for gutta-percha condensation: spreaders, pluggers.

The Millera root needle can also be used to fill root canals.

Spreader is a hand-held instrument designed for lateral condensation of gutta-percha pins in the root canal;

Plugger is a hand-held instrument for performing vertical condensation of Gugga _ pepper in root canals

11. Anatomy of teeth.

A person's teeth change only once. The teeth of the mixed bite are called temporary or milk teeth. Their eruption begins at 6-7 months of life and ends by 2.5-3 years. At 5-6 years of age, permanent teeth begin to erupt, and by the age of 13, temporary teeth are completely replaced by permanent ones.

The anatomical formula of the teeth of the temporary occlusion is 2.1.2, i.e. on each side there are 2 incisors, 1 canine, 2 molars, a total of 20 teeth.

There are 32 teeth in the permanent dentition. Anatomical formula – 2.1.2.3, i.e. 2 incisors, 1 canine, 2 premolars, 3 molars.

In teeth there are:

– crown (corona dentis) – part of the tooth protruding into the oral cavity;

– neck of the tooth (colhim dentis) – anatomical formation where the crown of the tooth passes into the root.

Inside the tooth there is a cavity (cavum dentis), which is divided into the radicular part (cavum coronale) and root canals (canalis radicis dentis), in the apex area the roots end in a narrow apical opening (foramen apicis dentis).

Features of the structure of the root apex:

– physiological narrowing of the canal (physiological apex);

– apical foramen (anatomical apex);

– root cement (radiological apex).

In accordance with the Paris anatomical nomenclature, the following tooth surfaces are distinguished:

1. Frontal group - vestibular (fades ve.stibularis), lingual (f.lingvalis), contact surfaces (f. medialis, f.laferalis), cutting edge.

2. Chewing group – vestibular (f.vestibularis), lingual (f.lingvalis), contact surfaces (f.anterior. f.posterior), chewing (f.masticatoria).

Buffs are the most elevated part of the tooth on the chewing surface (immune zone against caries).

Fissures are natural depressions on the occlusal (chewing) surface of the tooth.

The equator is the largest perimeter of the tooth crown relative to the vertical axis.

Whether a tooth belongs to the right or left half of the dental cavity is determined by a combination of 3 characteristics:

1) root sign - the apices of the roots of the incisors and canines are deviated from the midline laterally, in premolars and molars - distally;

2) a sign of crown curvature - the most convex part of the vestibular surface of the crowns, displaced medially or anteriorly (in molars);

3) angle sign - the angle formed by the cutting edge and the medial surface is more acute than the angle formed by the cutting edge and the lateral surface of the teeth.

Functions of teeth:

a) incisors, canines - write for biting;

b) premolars - for crushing;

c) molars - for grinding.

In the clinic, the position of the tooth in the dentition can be indicated graphically or in a two-digit way (according to WHO):

1) graphic: (Zsigmond-Palmer system)

Permanent teeth Temporary teeth

Each tooth of the upper and lower jaw on the right and left has its own serial number from the midline. For example: 6 |; |4 .

Icon _| denotes the right half of the jaw, 6 – tooth formula, the icon denotes the left half of the jaw, 4 – tooth formula, b] G4 – lower jaw. Dental formula according to WHO (two-digit formula). The side of the jaw is indicated by the number:

1 – upper jaw right side

2 – upper jaw left side

3 – lower jaw left side

4 – lower jaw right side

Permanent dentition Milk dentition

Segments: 1234 – for permanent dentition

5678 – for temporary occlusion

For example, to write down the formula for the second molar of the lower jaw, the designation 37 is placed on the left, i.e. 3 – formula of the left segment of the lower jaw, 7 – formula of the tooth.

Rostov State Medical University

Department of General Surgery Rost State Medical University

INFORMATION MATERIAL

for first-year medical and preventive medicine students undergoing internship as an “assistant junior ward nurse”

Compiled by:

Assoc. A.I.Maslov, associate professor V.V. Skorlyakov, ass. S.Yu.Efanov, ass. O.V.Baev

Under the general editorship of Honorable. activities science, prof. V.N. Chernova

Rostov-on-Don, 2012

1. Ethical and deontological principles of work and standards of medical personnel in a hospital. Legal responsibility of medical personnel

Medical deontology is the science of what is proper, i.e. about how a medical worker must behave in various situations of communication with patients, relatives of the patient and professional colleagues.

The term “deontology” itself comes from the Greek words “deon”, deontosis - due, proper, and “logos” - doctrine.

This is a set of concepts such as ethics, aesthetics, morality, law, mercy, integrity. In this case, education, literacy, and professionalism play a huge role. The behavior of a medical worker and his words must necessarily lead to the creation of the best, optimal conditions for treatment for patients, despite the nature of the disease.

Basic deontological principles:

Responsibility;

Do no harm;

Mercy;

Medical confidentiality;

Behavior.

The physician must take responsibility in determining the prescription of this or that medicinal product, one or another treatment method. When determining the indications for surgery, the surgeon decides in the interests of the patient how much the outcome of the operation exceeds the risk of the disease itself.

Compliance with the principle “Do no harm!” is possible only if a medical worker has such a quality as the highest degree of self-criticism, the ability to correctly and soberly evaluate himself and his actions. Every surgeon, before deciding to perform an operation, must ask himself whether he would agree to perform a similar operation on himself or his loved ones in similar circumstances, and only if this question is resolved positively - to operate.

Mercy is largely a quality that is cultivated from childhood and adolescence through the example of surrounding adults, and during the period of thinking - on the basis of self-education. Andre Maurois wrote: “Charity is not an indispensable adornment of a physicist or a chemist, but it is obligatory for a general practitioner or surgeon.”

If you see that a patient is groaning while changing the dressing, and one of the students is looking distractedly out the window, whispering, smiling - he clearly does not have enough quality for a medical worker to be compassionate.

Medical confidentiality should be understood as all information received from a patient or revealed during his medical examination or treatment, which is not subject to disclosure without the patient’s consent.

The behavior of medical personnel in the reception department, wards, operating and dressing unit, in the lobby, etc. is an important factor influencing the psyche of patients and their trust in medical staff.

Great attention should be paid to wearing a gown, cap, change of shoes in the department, and a mask in the surgical department. A neat appearance, goodwill, balance, and correctness create the best conditions for a patient in the treatment and prevention department.

It is noteworthy that the problem of the doctor’s relationship with the patient has long been considered in terms of their cooperation and trust. Thus, the doctor and writer Abu al-Faraj, who lived in the 13th century, formulated the following address to a sick person: “There are three of us - you, the disease and me; if you are sick, there will be two of you, I will remain alone - you will overcome me; if you are with me, there will be two of us, the disease will remain alone - we will overcome it.”

Medicine in modern world plays an exceptional role in human life and society. It is difficult to find a person who has not encountered it at all, meeting for the first time at birth and not parting until death. Therefore, the relationship between doctor and patient goes beyond ordinary relationships between people. They require not only the professional knowledge of the physician and his compliance with moral and ethical standards, but also knowledge of the legal foundations of protecting the health of citizens. This is especially important in our time, when, contrary to the established traditions of the relationship between a doctor and patients, features characteristic of the relationship between the producer of services and their consumer are acquired, and when they are regulated by legal norms.

In August 1993, the State Duma of the Russian Federation adopted the Fundamentals of the legislation of the Russian Federation on protecting the health of citizens. This document, in the development of the Constitution, sets out the basic principles of protecting the health of citizens, the organization of various health care systems, guarantees for the implementation of medical and social assistance, the rights of citizens and separate groups population in the field of health care.

2. Personal hygiene rules for medical personnel.

A medical worker of any rank must observe the rules of personal hygiene and maintain his health. This is necessary both for himself and for the patients he serves. A medical worker should be an example of high sanitary culture. No propaganda produces the same results as personal example. If a medical worker does not take care of his own health, then how can he teach how to take care of the patient’s health?

Hippocrates, the great ancient Greek physician (460–377 BC), spoke about the importance of the appearance of a medical worker. “A physician is told by authority,” said Hippocrates, “if he is of good color and well nourished, according to his nature, for those who themselves do not have a good appearance in their body are considered by the crowd to be unable to have proper care for others. Then, it is proper for him to keep himself clean, have good clothes and rub himself with fragrant ointments (that do not have a suspicious smell), for all this is usually pleasant for the sick.”

Maintaining a daily routine is the basic rule of personal hygiene. You should always get up in the morning and go to bed, have breakfast, lunch and dinner at the same time. You should correctly distribute the hours of work and rest, alternating mental work with physical work.

An important element of personal hygiene is diet. Eating at the same hours, rational selection of dishes, adherence to a quantitative and qualitative diet are extremely important for health.

A medical worker should not have bad habits, and if he has acquired them, he should try to get rid of them. Bad habits that are incompatible with the medical profession include smoking, alcohol abuse, etc.

To maintain health and prevent diseases, it is necessary to exercise and strengthen your body. Classes morning exercises with subsequent water procedures should become a habit.

A healthcare worker must carefully monitor the cleanliness of his body. The face and neck should be washed 2 times a day. You should also wash the perineal area with warm water 1-2 times a day. You need to wash your feet daily, especially for those who sweat. It is recommended to wash in the morning with cold water up to the waist (after physical exercise) or take a cold shower, and at night wash, rinse and wash your feet with warm water.

Hand care requires special attention. A medical worker washes his hands not only before eating and after visiting the toilet, but also before and after each medical procedure. Medical workers, especially those involved in surgery (surgery nurses, midwives, etc.), should protect their hands from contamination. You should wear gloves when performing dirty types of housework (washing the floor, cleaning the bathroom in the apartment, peeling vegetables, etc.). Nails should be cut short and filed. The skin edge of the nail bed should not be trimmed, as this is a common cause of the formation of hangnails and then ulcers. Painting your nails with polish is not recommended. You need to wash your hands with a brush. This is necessary, on the one hand, in order to cleanse the periungual and subungual spaces from dirt, and on the other, so that the skin in these areas becomes somewhat rougher.

Frequent hand washing leads to dry skin, so it needs to be constantly nourished, lubricating it daily at night and after work with some cream, you can use a mixture of glycerin and ammonia (1/4 ammonia and 3/4 glycerin) and rub this mixture into the skin after hand washing.

It is necessary to carefully care for your hair. It is recommended to wash your hair no more than once every 10–14 days. Hot water is used to wash oily hair; for dry hair, use warm water.

Hair should always be neatly combed; excessively voluminous hairstyles should be avoided, in which hair may come out from under a cap or headscarf during work.

Oral care is also of great importance, as neglect leads to tooth decay and bad breath. You should brush your teeth 2 times a day (at night and in the morning) and rinse your mouth after each meal. It is necessary to periodically see a dentist in order to carry out timely treatment if necessary. A person who neglects the requirements of hygiene and carelessly treats the condition of the oral cavity, turning it into a source of disease, cannot be considered cultured. Bad breath can also be due to other reasons that should be found out in order to get rid of this deficiency, which makes it difficult to communicate with people. When going to work, you should not eat strong-smelling substances (garlic, onions, etc.).

The medical worker is also obliged to observe clothing hygiene. Clothing must correspond to the time of year and climatic conditions, and its cut should be such as not to impede the blood circulation of individual parts of the body and the functioning of organs.

When choosing fabric for a work dress, you should take into account the nature of the work being performed. In most infectious diseases hospitals, maternity hospitals, and in a number of surgical departments, employees have individual closets designed to store not only work clothes, but also work clothes and work shoes. In such cases, you can purchase a dress made of any fabric to wear outside of work hours, and for work you can have a simple cotton dress that is easily washable.

For work, a skirt with a blouse is most convenient.

Outerwear and woolen dresses should be brushed or vacuumed more often, and contaminated areas should be cleaned with gasoline.

Underwear requires changing at least once a week. To sleep you need to have nightgown and under no circumstances go to bed in the underwear that has been on your body all day.

Shoes should be comfortable, not restrictive, with low heels. It is better to avoid shoes with microporous or rubber soles, since such shoes bring street dirt into a medical facility or into the patient’s apartment.

The medical worker's overalls consist of a gown, headgear and shoes. In surgical departments, maternity hospitals, infectious diseases and some other departments, special clothing also includes a dress and a mask.

The form of headgear for a doctor is a cap, for a nurse - a headscarf or cap, for a nurse - a headscarf. The fabric from which the headdress is made should be white, linen or cotton, easily washable. Any headdress must completely cover the hair. The robe is sewn from white cotton or linen fabric, which is not destroyed by frequent washing, boiling and treatment with disinfectants. The robe must cover the dress completely. For all medical workers, a robe with a fastener at the back is generally accepted; in some departments, a double-breasted robe is acceptable. The robe and headdress should be not just clean, but snow-white.

Medical personnel working in a hospital are required to wear slippers. This is dictated by the convenience of the worker and the interests of the patients, since there is no noise when walking in slippers. Slippers should be worn with leather or rubber soles, but not felt or fur, as they absorb dirt well and are difficult to sanitize.

Medical ethics requires that a medical professional not only observe the rules of personal hygiene, but also decency. Clothes should not only be clean, but also comfortable for doing the job. It should not irritate patients with excessive brightness or pretentious cut. Perfume or cologne should be used in moderation, and only those that do not have a strong odor. Modesty and moderation in the use of cosmetics and wearing various jewelry are dictated by the very nature of the work of a medical worker.

3. Requirements for organizing a nurse’s workplace.

One of the important sections of the scientific organization of labor (SLO), aimed at creating favorable conditions for effective and high-quality work, is the rational organization of the workplace and working conditions of medical personnel in outpatient clinics and hospitals. Poor workplace organization leads to wasted working time. It has been established that during a three-hour outpatient appointment, a local general practitioner has to search for a lost medical document, form, or medical record on average four times. The time spent searching for each document ranges from 10 seconds to 3.5 minutes. In addition to the loss of working time, this circumstance causes additional psycho-emotional stress in the work of the doctor and nurse, creates an unfavorable atmosphere at the reception, and negatively affects the state of the diagnostic and treatment process.

General requirements for workplace organization

The doctor's and nurse's desk should be in the most illuminated part of the office;

There must be space around the table that allows free movement of the doctor and nurse from the table to any object in the office;

The couch for examining the patient should be positioned so that the right half of the patient’s body is on the doctor’s side; the couch must be fenced off from the front door with a screen and a chair for the patient must be placed close to it;

The location of each item must be thought out in order to minimize the cost of movement and ensure compliance with aesthetic requirements in the design of the office;

The office door must be visible so that the doctor can see the patient entering.

Hygienic requirements for the organization of workplaces in medical offices provide for compliance with basic sanitary and hygienic standards: sufficient area, cubic capacity and footage per worker, microclimate parameters, lighting, noise, etc.

Ergonomic, hygienic and aesthetic requirements for the organization of workplaces are set out in the relevant regulatory and methodological materials.

Maintenance of workplaces includes organizing document flow, providing medications, standard forms and instruments, organizing sick calls, preparing workplaces and cleaning premises.

In the rational organization of workplace services, an important place should be given to the use of standard forms for referrals for research and treatment. Taking into account the fact that it is necessary to explain to the patient where and in which office he needs to appear, how to prepare for the study, unproductive costs of working time increase significantly. Therefore, the rationalization of this element of the work of medical personnel has a significant benefit in the work of healthcare facility specialists. It is recommended to use standard referral forms for certain types of research. The front side of each referral form consists of two sections.

In the first section, the nurse enters the patient's last name, initials, medical card number and address, as well as the doctor's last name and date of appointment. The second part is intended to fill out the results of the study of auxiliary diagnostic services. The reverse side of the form has a memo for the patient, including information about the rules of preparation for the study, the place and time of its conduct. The presence of such forms completely frees the doctor from writing directions and saves the nurse’s working time. Referral forms must be placed in the table's blank file, only in this case they are convenient to use.

With a rational organization of the workplace, the issues of reducing the time spent on maintaining a medical record of an outpatient patient, which occupy at least 25–30% of the working time at the reception in the work of doctors of main specialties, require solutions. For this purpose, it is currently recommended in clinics to use cliched inserts in the medical record, which allow, by emphasizing the signs listed in them and entering the missing ones in specially designated lines, to significantly reduce (by 15–20%) the costs of doctors for filling out a medical record. Inserts can be printed by printing or by making a rubber cliche. In the latter case, they are printed as needed directly in the doctor's office.

Thus, thoughtful organization and maintenance of the workplace, its equipment and equipment, taking into account the requirements of ergonomics and aesthetics, rational layout of the office should be aimed at creating conditions for effective and high-quality work of a doctor and nurse conducting an outpatient appointment.

Approved
Main Directorate
treatment and prophylactic
assistance from the USSR Ministry of Health
December 23, 1983 N 10-11/2
Agreed
Trade Union Central Committee
medical workers
November 17, 1983 N 04/Ш
METHODOLOGICAL RECOMMENDATIONS
ON ORGANIZING A DOCTOR'S WORKPLACE
AND THE NURSE OF THE POLYCLINIC
Methodological recommendations were prepared by employees of the Department of Medical Information for Workers of Healthcare Institutions of the All-Russian Research Institute of SG and Healthcare named after. N.A. Semashko (Yu.I. Zotov, G.I. Kutsenko, V.S. Vasyukova, D.K. Eremina, head of department, Doctor of Medical Sciences V.F. Minakov) and the Social Insurance Council of the Central Committee of the Trade Union of Medical Workers (V .S. Shurupova, N.I.
One of the important sections of scientific labor organization (SLO), aimed at creating favorable conditions for effective and high-quality work, is the rational organization of the workplace and working conditions for medical personnel in outpatient clinics. However, to date, this issue has not yet received due attention in the country's clinics. Office desks used in the practice of doctors and nurses are of little use for putting things in order in the workplace due to their limited coverage area and lack of facilities for placing medical documentation, instruments and office equipment. Often at a doctor’s workplace you can find a mountain of medical records, different forms, directions, glasses with spatulas and thermometers, which creates crowding and chaos. Poor workplace organization leads to wasted working time. It has been established that during a three-hour outpatient appointment, a local general practitioner has to search for a lost medical document, form, or medical record on average four times. The time spent searching for each document ranges from 10 s to 3.5 m. In addition to lost working time, this circumstance causes additional psycho-emotional stress in the work of the doctor and nurse, creates an unfavorable atmosphere at the reception, and negatively affects the state of the diagnostic and treatment center. process.
Specially conducted studies have shown that many elements of a doctor’s work during an outpatient appointment are performed in forced, non-physiological positions, which leads to a rapid increase in fatigue of various parts of the musculoskeletal system, the development of functional insufficiency and discomfort in them, and also negatively affects the quality of diagnostic work, especially at the stage of physical examination of the patient. To a large extent, the forced working postures of medical workers at outpatient appointments is associated with the irrational organization of workplaces: imperfect equipment, incorrect selection and placement of furniture, its inconsistency with the specifics of work, anthropometric data and physiological capabilities of workers.
Improving the organization and maintenance of workplaces in health care institutions should be aimed at creating optimal conditions that ensure a high level of performance of medical personnel and a more complete use of the working time of doctors and nurses for basic types of work.
Experience in the rational organization of labor in the country's leading institutions: polyclinic No. 22 in Kyiv, polyclinic No. 1 in Novopolotsk, a number of outpatient clinics in Riga, Dushanbe, the outpatient department of the Aluksen Central District Hospital of the Latvian SSR, etc. and the results of scientific research carried out Department of NOT VNII SG and OZ named after. N.A. Semashko, made it possible to identify the basic requirements and outline measures to improve the organization of workplaces for doctors and nurses conducting outpatient visits.
General requirements for workplace organization
The workplace should be understood as the area of labor activity of an employee or group of employees, equipped and equipped with everything necessary to perform their official duties. When organizing workplaces for medical workers, the type of institution and the profile of the specialist are first taken into account, that is, the workplace must be specialized.
The rational organization of any workplace in a medical institution must include equipment, rational layout, organization of workplace maintenance, compliance with ergonomic, aesthetic and sanitary-hygienic requirements.
Equipping workplaces is one of the main conditions for the rational use of labor of medical workers and involves providing each workplace with a set of furniture, special instruments and equipment, office equipment, standard forms, etc. When equipping, it is necessary to take into account the nature of the workers’ work activities.
The rational placement of medical furniture and equipment in the doctor’s office is important in organizing the workplace. In accordance with ergonomic requirements (see below), as well as based on observations of the actions of the doctor and nurse, it is recommended that the furniture and equipment of the doctor’s office be placed in accordance with the following rules:
- the doctor’s and nurse’s desk should be in the most illuminated part of the office;
- there must be space around the table to allow free movement of the doctor and nurse from the table to any object in the office;
- the couch for examining the patient should be positioned so that the right half of the patient’s body is on the doctor’s side; the couch must be fenced off from the front door with a screen and a chair for the patient must be placed close to it;
- the location of each item must be thought out in order to minimize the cost of movement and ensure compliance with aesthetic requirements in the design of the office;
- the office door must be visible so that the doctor can see the patient entering.
Ergonomic requirements for the organization of workplaces determine the compliance of the design data and dimensions of work furniture and organizational equipment with the anthropometric, biomechanical and psychophysiological capabilities of the human body. Compliance with them makes it possible to provide a medical worker with a physiologically rational posture during work that meets the criteria of functional comfort.
Hygienic requirements for the organization of workplaces in medical offices provide for compliance with basic sanitary and hygienic standards: sufficient area, cubic capacity, footage per worker, microclimate parameters, lighting, noise, etc.
Aesthetic requirements for the organization of workplaces provide for the implementation of a set of recommendations for the artistic design of work premises, office interiors, and the institution as a whole.
Ergonomic, hygienic and aesthetic requirements for the organization of workplaces are set out in the relevant regulatory and methodological materials.
Maintenance of workplaces includes organizing document flow, providing medications, standard forms and instruments, organizing sick calls, preparing workplaces and cleaning premises. In recent years, in many medical institutions, centralized provision of workplaces with everything necessary has become widespread.
In the rational organization of workplace services, an important place should be given to the use of standard forms for referrals for research and treatment. As observations have shown, the frequency of referrals, for example, in the office of a local general practitioner is on average 23 times by a doctor and 46 times by a nurse per 100 visits, and in an ENT office - 21 and 31, respectively. An average of 1.4 m is spent on issuing one referral. Taking into account the fact that the patient needs to be explained where and in which office he needs to appear, how to prepare for the study, the unproductive expenditure of working time increases significantly. Therefore, the rationalization of this element of the work of medical personnel has a significant benefit in the work of clinic specialists. It is recommended to use standard referral forms for certain types of research (Appendix 2 - not provided). The front side of each referral form consists of two sections. In the first section, the nurse enters the patient's last name, initials, medical card number and address, as well as the doctor's last name and date of appointment. The second part is intended to fill out the results of the study of auxiliary diagnostic services. The reverse side of the form has a memo for the patient, including information about the rules of preparation for the study, the place and time of its conduct. The presence of such forms completely frees the doctor from writing directions and saves the nurse’s working time. Referral forms must be placed in the table's blank file, only in this case they are convenient to use.
The use of pre-prepared prescriptions significantly saves a doctor’s working time. It has been established that the frequency of their discharge is, for example, an average of 100 - 150 per 100 visits for an otolaryngologist, and 200 - 250 for a local general practitioner, respectively. Specially conducted studies have shown that an otolaryngologist operates on approximately 100, and local doctor 140 - 160 prescriptions, most of which are used repeatedly during the working day and week. Taking into account the above, the optimal volume of the prescription library should be designed for 40 - 60 prescriptions.
With a rational organization of the workplace, the issues of reducing the time spent on maintaining a medical record of an outpatient patient, which occupy at least 25 - 30% of the working time at the reception in the work of doctors of main specialties, require solutions. For this purpose, it is currently recommended in clinics to use cliché inserts in the medical record (developed at the N.A. Semashko All-Russian Research Institute of SG and Healthcare), which allows, by emphasizing the signs listed in them and entering the missing ones in specially designated lines, to significantly reduce (by 15 - 20%) costs for doctors to fill out a medical card. Samples of such inserts for a local general practitioner and an otolaryngologist are given in Appendix 3 (not provided). Inserts can be printed by printing or by making a rubber cliche. In the latter case, they are printed as needed directly in the doctor's office.
Maintaining functional connections between doctors at outpatient appointments is ensured by equipping workplaces with means of communication with all the main departments and services of the clinic: the registry, the offices of specialist doctors, the head of the department, and auxiliary treatment and diagnostic rooms.
To call a patient to the doctor’s office, it is advisable to use a light or sound alarm. When using a light alarm, a light sign is installed at the door of the office with the inscription “Do not enter”, which is illuminated while receiving a patient, and “Enter” when the doctor has received the patient and is calling the next one. In this case, the doctor’s workplace is equipped with a light signal switch. In the second option, any intercom communication device operating in loud-speaking mode is used (for example, PU-1).
Thus, thoughtful organization and maintenance of the workplace, its equipment and equipment taking into account the requirements of ergonomics and aesthetics, rational layout of the office should be aimed at creating conditions for effective and high-quality work of a doctor and nurse conducting outpatient visits.
Next, we will consider, as an example, the features of organizing workplaces for specialists in therapeutic and surgical profiles - a local general practitioner and an otolaryngologist.
Organization of the workplace of a local physician-therapist
For a doctor conducting an outpatient consultation, his desk is his workplace. Currently, taking into account the disadvantages associated with the use of conventional office tables in the work of local therapists, a number of functional tables have been proposed.
The outpatient doctor’s work desk, designed by P.E., has proven itself well. Beilin, which is used in clinic N 22 in Kyiv. It consists of four rectangular boards, three of which are vertical, installed in an H-shape, the fourth covers them horizontally. Equipment: a tape recorder, a microphone, a Riva-Rocci apparatus, glasses with spatulas and thermometers are “recessed” into the table cover, and glasses with disinfectants for storing thermometers and spatulas are also placed. Medical supplies are placed on the table in designated work areas. The table is equipped with a portable recipe library for 24 cassettes, mounted in the front drawer of the table. A folding board is provided to organize the nurse's workplace. The table can be recommended for use in clinics that have implemented a tape recording method for recording medical records.
The Republican Center for Medical Information Technology and the Health Department of the Ministry of Health of the Latvian SSR have proposed a unified table for a local physician, which is used in a number of clinics in Riga. On the horizontal plane of the table there is a recess for a tonometer, secured with a special bracket. The tabletop drawers contain directions for examinations and treatment, personal items for doctors and nurses. The top drawer of the table base is intended for short-term placement of medical records of outpatients. Delivery of medical records to the doctor’s office is carried out using containers, which are stocked at the reception desk in the order in which patients are seen by the doctor. Desktop file cabinets for A-5 format cards, produced by industry, are used as containers. The bottom drawer of the support cabinet of the specified table is intended for the personal belongings of the doctor and nurse. This table is recommended to be implemented in the work of a local general practitioner, whose work organization involves the use of standard directions for examinations and treatment, delivery of medical records in special containers.
Department of Notifications for Workers of Healthcare Institutions of the All-Russian Research Institute of SG and Healthcare named after. N.A. Semashko, together with the All-Union Design and Technological Institute of Furniture, proposed a doctor’s and nurse’s desk that uses printed inserts for medical records, standard referral forms, and pre-made prescriptions. The table has a slightly larger working surface (1280 x 940 mm) compared to a regular office desk. This allows you to organize a workplace for a doctor and a nurse at one table. Under the table cover, along the middle line on both sides, there are two flat drawers measuring 198 x 512 x 60 mm, designed to accommodate reference literature, site passports, and office supplies. The surface of the table has two zones - for the doctor and the nurse; in addition to the table there is a filing cabinet in the form of two bedside tables on wheels. Drawers in bedside tables act as containers for placing inserts of medical records, standard directions, registration forms, temporary storage of medical records, placement of control charts of dispensary patients, etc. The drawers of the bedside tables are pulled out using hanging hinges, which allow you to hold the extended containers in a horizontal position for the entire length. The presence of a separate form-card file allows you to install it in a place convenient for the doctor and nurse. There is a special device on the table surface for attaching the tonometer.
Consequently, the choice of recommended work desks for a local doctor and a clinic nurse depends on the forms and methods of organizing work and servicing workstations at an outpatient appointment.
Aesthetic and hygienic requirements for the design of a local therapist's office are established in accordance with SNiP II-69-78 "Medical and preventive institutions. Design standards", according to which the area of the office should be 12 - 16 square meters. m (with a room width of at least 2.4 m and a depth of 4 - 6 m in conditions of one-sided lighting). The ratio of the depth of the room to its width should be no more than two.
The coloring of walls can influence the perception of the color of pathological tissues, emphasizing or, conversely, masking their pallor, cyanosis, etc. In this regard, it is preferable to paint the walls of the room in neutral colors, for example, light gray. The ceiling is painted white, the floor dark. It is advisable to have curtains on the windows in yellowish shades, and desk coverings in a green range of colors.
The optimal air temperature in the office according to GOST 12.1.005-76 "Air of the working area. General sanitary and hygienic requirements" in cold and transition periods of the year should be within 20 - 23 ° C, in the warm period of the year - 20 - 25 ° C at relative humidity 60 - 40% and air speed no more than 0.2 m/s in all periods of the year. In order to avoid disturbance of thermal equilibrium and cooling of patients during physical examination, it is necessary that the difference in air temperatures horizontally (from external walls to any point inside the room) and vertically (between the floor and a height of 1.5 - 2 m) does not exceed 1 - 2 °C . The frequency of air exchange in the office at least 1 time per hour is ensured by the use of natural ventilation.
According to GOST 12.1.003-76 “Noise. General safety requirements,” the noise level in offices should not exceed 30 dB, and in rooms for receiving patients in noisy industries, noise levels should not exceed 50 dB.
Bacterial contamination of the air in work areas should be no higher than 4000 colonies per cubic meter. m of bacteria and 50 colonies per cubic meter. m representatives of hemolytic microflora.
The hygienic regime of the premises provides for wet cleaning twice a day.
The nature of the work of community therapists requires high levels of both natural and artificial lighting. At the same time, according to SNiP II-4-79 “Natural and artificial lighting. Design standards”, the normalized values of the coefficient of natural lighting (KEL) are 1.5 - 2.0; artificial illumination at the level of the table surface must be at least 300 lux and is provided by general lighting. Considering the high requirements for color discrimination in the work of a local physician, preference should be given to fluorescent lamps with optimal color characteristics as a light source. For lighting offices, lamps such as LHE, LDTs can be used.
In order to create an aesthetically pleasing workplace in the office of a local general practitioner, it is necessary to provide landscaping, which also acts as a factor that improves the microclimate.
Organization of a workplace for an otolaryngologist
The office of an otolaryngologist in accordance with SNiP II-69-78 is organized in a room with an area of 18 square meters. m, having at least 6 m in length, which is necessary for studying hearing in patients with whispered and spoken speech. For the same purposes, good sound insulation should be provided when constructing the cabinet. It is recommended to place the ENT office in two adjacent rooms, one of which is intended for receiving patients, the other for complex manipulations and outpatient operations. New projects of outpatient clinics for 750 or more visits per day provide an operating room with a preoperative area of 22 square meters next to the otolaryngology office. m (14 sq. m + 8 sq. m).
The optimal air temperature in the ENT office is 18 - 20 °C, in the warm season - up to 25 °C. The frequency of air exchange is once per hour. If washing and drying surgical instruments are carried out directly in the workroom, the air exchange rate should be increased by three times the exhaust per hour. If there is a fume hood in the office in which work with biologically active drugs is carried out, optimal air conditions in the office can be ensured by natural ventilation.
Other hygienic indicators of the air environment correspond to the normative standards for the offices of local general practitioners.
One of the unfavorable factors in the working conditions of otolaryngologists is extensive contact with infection, which is confirmed by the high incidence of acute respiratory diseases among specialists in this professional group, identified during a special study. Taking into account this circumstance, special attention should be paid to measures aimed at reducing bacterial contamination in work areas.
The surface of walls and ceilings must be smooth, allowing wet cleaning and disinfection. The floor must be covered with a waterproof material that is easy to clean and can be frequently treated with a disinfectant solution.
It is more effective to sanitize air directly in the presence of people. For this purpose, the method of air disinfection with bactericidal lamps should be used. The domestic industry produces a wall-mounted bactericidal irradiator NBO, consisting of two lamps (BUV-30P): the upper (shielded) one irradiates the upper zone of the room in the presence of people, then the disinfected air flows through convection currents into the breathing zone of personnel and patients; the lower (open lamp) produces a short powerful irradiation in the absence of people for 15 - 20 m. Irradiation of the room with it after wet cleaning (before starting work and during breaks between shifts) ensures the death of pathogenic microflora, which plays an important role in the etiology of acute and chronic diseases of the upper respiratory tract. When using UV rays for disinfection, the walls and ceiling of the room should be painted with yellowish oil paint that has an optimal reflection coefficient for ultraviolet rays.
When organizing the workplace of an ENT doctor and nurse, the use of ergonomically sound furniture is of great importance. According to a special study, otolaryngologists at outpatient appointments in the current working conditions spend more than half of their working time in forced positions. The non-physiological postures of otolaryngologists are primarily due to the specifics of the diagnostic and treatment process of persons in this specialty. The main elements of labor activity when examining patients and performing medical manipulations are carried out with non-fixed hands while tilting the body forward by 17 - 25°. This causes tension in the muscles of the back, upper shoulder girdle and is a significant load for the anterior sections of the cervical and thoracic vertebrae. Large service spaces (reach zone up to 1200 mm) force the doctor to make a significant number of forward and side bends (about 450 - 500) during one appointment. The situation is aggravated by the irrational organization of the workplace, which leads to rapid fatigue of various parts of the musculoskeletal system that bear the main load in these positions. This is confirmed by numerous complaints, as well as indicators of the state of the cardiovascular and muscular systems.
A peculiarity of the work of persons in this specialty is a deficit of motor activity: the dynamic component in the work of an otolaryngologist is only 4.7% of the working time. In these conditions, much attention should be paid to the rational organization of the working posture of the doctor and nurse in the ENT office. To do this, medical office staff must be provided with functional chairs. Since the otolaryngologist almost never leaves his workplace, the design of the work chair must provide conditions for short-term rest (maintaining the doctor’s body in a physiologically rational position while maintaining the natural curves of the spine, rest for the arms), for which the chair must be equipped with a backrest with armrests.
The otolaryngologist's chair must be movable in a horizontal plane with the ability to automatically fix it in the desired position. Rotation of the chair around the vertical axis of the supporting structure by 180° allows you to bring the size of the reach zones closer to optimal values. The mobility of the posture is also ensured by a flat semi-soft seat, covered with a softened, water-repellent, non-electrifying and airtight material. Of the work furniture produced by the domestic industry, the chair designed by the Volgograd Medical Equipment Plant meets these requirements to the greatest extent.
A rationally organized workplace for an otolaryngologist at an outpatient appointment includes a table for instruments (suggested by doctor A. Heeger) and a functional work desk. The instrument table is located to the left of the doctor. It provides the otolaryngologist with a comfortable posture during examination and treatment procedures. The table area, 1000 x 600 mm, allows you to rationally place all the necessary items and tools and install a work lamp at the required distance. The presence of another working area of the table, located below and parallel to the main one, allows you to timely free the working area from used tools.
It is advisable to use the functional table described in the previous section as an otolaryngologist’s work desk. The nurse’s workplace in this case is located at the same table, opposite the doctor. At some distance from the doctor’s and nurse’s workplace there is a table for instruments. This allows the nurse to actively assist the doctor in carrying out therapeutic and diagnostic procedures, as well as perform a number of independent manipulations prescribed by the doctor. As a result, the efficiency and volume of work of the ENT office increases.
The patient's chair should be rotating with headrests, which allows the head to be fixed when performing manipulations and outpatient operations.
The specific work of an otolaryngologist requires a certain degree of darkening of the office, which leads to contrasts in the illumination of objects in the surrounding space. At the same time, during otoscopy, laryngoscopy, and surgical interventions, the doctor has to deal with the small size of the observed objects, which necessitates bright illumination of the field of view. The frequent re-adaptation of the visual organ that occurs in these cases leads to a decrease in visual performance, the rapid development of fatigue, and with prolonged exposure - to pathological changes in the visual organ. Taking into account the above, special attention should be paid to rational lighting of the workplace. In order to provide favorable conditions for re-adaptation of the eye, the ratio of brightness levels of the workplace and the surrounding background should not exceed 1:3. To comply with this requirement, the walls and floor of the ENT office should be painted in light colors with a high reflectivity. For more uniform illumination and to eliminate glare caused by sunlight, the orientation of the ENT office is preferable to the north. To protect against direct and reflected sunlight, it is necessary to have sun protection devices on the windows (for example, blinds), which allow you to create the desired degree of darkness in the office.
The required levels of illumination in the ENT office are created using a combined lighting system. On the surface of the desk, the illumination should be at least 300 lux. The illumination of the viewing area when examining a patient is created by light reflected from the working lamp, which is located at a distance of 10 - 15 cm from the patient and 60 - 70 cm from the doctor. As a light source in a work lamp, it is recommended to use 60 W incandescent lamps in a bulb made of milky (frosted) glass, which does not have a pronounced glare effect on the organ of vision. Incandescent lamps of this power provide an illumination level of 700 - 750 lux sufficient for examining ENT organs. Lamps attached with a bracket or mounted in the patient’s chair are convenient to use.
Important importance in organizing the workplace of an otolaryngologist and a nurse should be given to the layout of the office with the rational placement of furniture, necessary items and means of labor of the medical staff of the ENT office, taking into account ergonomic requirements, the separation of areas of activity of the doctor, nurse and the flow of visitors.
The rational organization of workplaces for doctors and nursing staff in outpatient clinics is based on knowledge of the specifics of the labor process, as well as compliance with hygienic, psychophysiological and ergonomic requirements for the working areas and working conditions of each specialist. The selection of functional furniture, the correct distribution of labor items and organizational equipment in the workspace, the use of rational forms and methods of organizing work allows you to avoid clutter and disorder in the workplace, eliminates unproductive waste of working time, and reduces the increase in fatigue. Only the comprehensive implementation of all the described measures makes it possible to create the necessary conditions for the effective and high-quality work of medical personnel in medical institutions.