Postscripts in the electronic medical record. Maintaining an integrated electronic medical record

In 2018, Russians will get another new feature - electronic medical records will appear instead of regular ones. IN modern life everything suddenly became “electronic”: e-government, e-services, e-books and libraries. What is this - a fashion trend? Undoubtedly!

But, on the other hand, our lives are rapidly changing, becoming “electronic” in many areas: air ticket offices have almost completely moved to the Internet, non-digital photography has remained the lot of aesthetes, and paper books are clearly losing their position.

IN lately It became noticeable that in the Moscow metro there were clearly more electronic books and tablets in people’s hands than regular books and magazines.

Information technologies are actively being introduced into the field of medicine: “electronic registries” are already in operation, with the help of which you can make an appointment with a doctor without leaving your home, and In 2018, every Russian will have virtual medical cards.

What are the advantages and disadvantages of this software product, on what scale its implementation will be carried out, we’ll talk about this further.

Key facts about electronic medical records in 2018: advantages and disadvantages

In private clinics, virtual filing cabinets began to appear in 2015;
The Ministry of Health and the Ministry of Communications plan to implement the project by 40% in 2018;
The implementation of the software product will be financed from the federal budget, for which 160 billion rubles have been allocated;
Simultaneously with the introduction of electronic registries, the government plans to solve the problem of connecting rural hospitals to the global computer network;
The leader in the implementation of information technologies is Moscow: today they are used by almost 10% of city residents and 30% of doctors;
Each owner of a virtual medical card will be able to view it at any convenient time on the government services portal in personal account patient, created in the spring of 2017.

Electronic medical record (EMR) – a set of electronic personal medical records related to one person, collected, stored and used within one medical organization

Personal electronic medical record (PEMR) - an analogue of a paper medical record

This is an analogue of a paper card, to which only the doctor and the patient have access. Here you can find personal data, information about vaccinations, blood type, Rh, previous diseases, which specialists the patient is registered with, test results, ultrasound, and x-rays.

Video: every Russian will have an electronic medical record by 2019

In the future, it is planned to create a unified database nationwide, which will include all medical institutions, both commercial and government. A doctor from any hospital, from any city will only need to enter the patient’s data in an electronic file in order to get acquainted with his medical history, prescribe competent treatment, and provide advice.

Advantages of electronic patient records over paper versions

Simplifies the work of the registry: medical staff do not need to waste time searching for a medical card, preventing its loss or damage;
The laboratory enters test results into the PEMC. This will save the medical institution from monetary costs for the delivery of laboratory tests and will reduce the likelihood of their loss;
Optimizes the doctor’s work with the patient. The electronic medical record is filled out according to templates, which simplifies the entry of information. This will allow the specialist to spend more time examining the patient rather than doing paperwork;
Information about each patient will always be at the doctor’s disposal. Various specialists can familiarize themselves with its contents, which will allow them to make the correct diagnosis and prescribe competent treatment;
A Russian citizen can familiarize himself with the contents of his own medical card in his personal account on the government services portal, with the doctor’s recommendations if the prescription has been lost;
There have long been jokes about the handwriting of Russian doctors. With the introduction of PEMK, people will forever forget about the problem of deciphering the diagnosis and prescribed treatment;
A person who has an electronic card can be sure that information about his diseases will not end up in the hands of strangers. After all, only a doctor has access to the electronic catalog.

Video: EHR in medical institutions of the republic

Disadvantages of PEMK: training of specialists, costs for equipping a doctor’s workplace, system failures during a power outage

It takes time to train specialists to work with electronic catalog. The older generation of doctors has a biased attitude towards modern information technologies, and therefore is wary of innovations. The doctor must learn how to quickly and correctly enter data about the patient, because the appointment takes 10-15 minutes;
Significant costs for equipping a doctor’s workplace: there must be a computer connected to the Internet and a printer. It is planned to introduce the position of a programmer responsible for the operation of a unified electronic database, which entails additional funding from the regional or federal budget;
News reports daily about computer hacks in the banking system government agencies. There is a high probability that this will happen with an electronic catalogue. On the Internet, for a fee, you can get access to the database of numbers of a mobile operator or the traffic police, what if PEMKs are freely available?
Commercial clinics have been testing electronic medical records for the past two years. The main problem they face is system failures associated with Internet or electricity outages. To date, there is no solution to how to receive patients if a medical facility is without power for a long time;
The issue of creating backup copies of PEMC in case of system failure has not been resolved;
The human factor plays an important role. Elderly people have a negative attitude towards modern technologies and half may refuse to use the software product. The clinic will have to continue to use paper medical records;
The issue of transferring existing information to a virtual catalog is relevant. This is a time-consuming endeavor: digitizing a single patient record will take hours and days. The work is performed by a qualified specialist, whose wages require additional expenses. Today, doctors use two types of medical records simultaneously: paper and electronic.

Fact 1. A paper duplicate is still needed

The standard for maintaining an electronic card is enshrined in GOST R 52 636–2006, and records that comply with this GOST have the status of an outpatient card. But, since the order to maintain a paper outpatient card is still in force, it is not yet possible to limit ourselves to only the electronic version. Most often, information is duplicated in ordinary paper cards, which allows data to be transferred to other health care facilities that are still not equipped computer system or maintain electronic cards using another program. The simplest option is to periodically print out data from the information system and enter it into a paper map.

Fact 2. Multi-accessibility

The clinic database is structured like this: in the health care facility they create local network with centralized management, similar to the Internet, protected according to the requirements of the law on maintaining medical confidentiality. There is a central server where all patient information is stored, divided into individual folders. From computers at workstations, you can view or change the contents of any folder at any time, depending on the access level. Thus, the patient’s “page” can be simultaneously filled out by different departments and specialists, for example, an ophthalmologist, a radiologist and a laboratory doctor who enters test results into the card. There is no need to move the card from place to place, there is no need to hand it out to the patient each time and track its return.

Fact 3. EHR simplifies many processes

With an electronic card, your life history is always at hand; it is available in a special tab or via a quick link. This will definitely simplify and speed up working with elderly patients with mnestic disorders. Also on the patient’s page you can see a list of updated diagnoses, a list of appointments and consultations, an allergy history, and data on the carriage of infections. Without digging through a paper map, without deciphering the handwriting of your colleagues, without searching through pieces of paper folded in half, you can quickly familiarize yourself with the results of examinations. You can book your appointment by filling out a special form, which can be customized individually. You can attach a drawing or photo to the inspection, the results of the manipulations performed. It simplifies the computer and the issuance of appointments and directions (the part of the appointment containing recommendations is automatically printed), as well as filling out coupons and encrypting the diagnosis according to the ICD.

Hippocrates never dreamed of medical cards, medical and childbirth histories, much less electronic versions of these documents! Read on to learn how the electronic future is invading hospitals and clinics.

An electronic medical record, or electronic medical record (EMR), is electronic document, designed for maintaining medical records, searching and issuing information upon requests (including via electronic communication channels).

The task of the Uniform State Health Information System is to promptly obtain information on volumes medical care services provided to the population to make it easier for the state to plan medical costs and optimize the expenditure of budget funds. In the future, the Uniform State Health Information System will become very convenient for practicing doctors. If we manage to get it working, consultations, hospitalizations, and transfers will be easier to process

Fact 4. EHR strengthens control

The use of electronic records makes the work of a medical organization more transparent in every sense. At any time, each record can be checked by management, insurance company, and supervisory authorities. Competent and timely internal control allows you to get closer to perfect documentation, which will help you avoid penalties during external audits.

Fact 5. Patient access will be denied

With a complete transition to electronic documentation, patients will not have direct access to their outpatient records. The patient will not be able to take the card home for his own personal reasons or remove the results of studies or tests from it, which is convenient for the clinic, which in this case will not face fines if this card is requested for verification. The information system, if necessary, allows you to quite simply and quickly print out a statement for the patient. There are projects for more technological solutions, for example, special card memory in the patient's hands, duplicating the outpatient card.

Fact 6. EHR will be implemented everywhere

The creation of a unified medical information system is a state initiative, which is recorded in order No. 364 dated April 28, 2011 “On approval of the concept of creating a Unified State Information System in the field of healthcare” (Uniform State Health Information System). So sooner or later computerization will be introduced everywhere.

Fact 7. Grandiose plans

Services planned in a unified information system federal level, for example, an integrated medical information record, imply a much higher level of storage and transmission of medical information than is currently the case. For example, if emergency or emergency hospital doctors have the opportunity to review a patient's outpatient record, this could save many lives.

What do you think?

I really like the electronic card, even though the transition to it was difficult. It is not possible to implement all functions at once, but we are getting there. Now we use it not only to keep track of cards, but also to track doctors’ working hours, payroll calculations, and a warehouse. There are many problems with training experienced specialists who come from regular clinics and have not worked on a computer. They are afraid. And young people get right up and work, they, of course, also have shortcomings, but we work, we check, it’s still easier than with paper.
Deputy chief physician for clinical expert work, polyclinic in the Moscow region

In general, in institutions that maintain an electronic medical history or outpatient card, the level of documentation is much higher. Apparently, this is due to the fact that the primary documentation is seriously checked by someone from the clinic administration.
Tatyana, medical expert at an insurance company

Still, there is no feeling of reliability from the electronic card. We’ve gotten used to cards over many years; I picked up the card and started accepting it. But on the computer you press something wrong, and it just goes away and gets deleted, or someone else edits the map — then look for the loose ends. And it turns out to be awkward with patients. You can write a card almost without looking, but asking a patient and looking at a computer is somehow impolite. Again, if the patient has already left, then the next one will immediately come in, you can put the paper card aside and return to it later, but with an electronic one it is more difficult. By the end of the day everything will be mixed up and you won’t be able to put it back together. Life doesn’t stand still, maybe we won’t be able to do without a computer later. It’s already convenient with analyses—everything is with numbers, printed, directions are drawn up by themselves.
Olga, therapist of the highest category, 16 years of work experience

The electronic map is not perfect, but it is better than scribbling. Checking boxes, instead of writing the same thing a hundred times, still saves a lot of time. But for now you have to print out the appointment, sign it and stick it on the card — this doesn’t make much sense. Moreover, if the patient came, for example, only for a rinse, he still has to register it as an appointment so that the insurance company will pay for it, and this is not very convenient. But in principle, filling out a card is no more difficult than filling out a page on a social network, so there are no problems with the database.
Larisa, ENT doctor of the first category, 11 years of work experience

Correctly filling out a patient's outpatient card has great value for doctors, since it is in it that all information about a person’s disease is stored. The map also becomes evidence in legal proceedings, if any arise. With the help of this document, you can medical examination, checking the work of specialists. For insured people, the medical card will serve as confirmation of the insured event.

Valid card form

In 2015, the Russian Ministry of Health issued a new order (“On approval of unified forms of medical documentation used in outpatient settings and the procedure for filling them out”), according to which all medical documentation and the rules for filling it out were updated. This order is of great importance, as it allowed medical institutions to carry out continuity among themselves.

The new outpatient card has undergone major changes. It contains more detailed information about the sick person, since it now contains specific points and sub-points. They must be filled out without fail. Until 2014, patient records were not made in such detail by different doctors. The order obliges to record information about consultations with doctors and managers. It is mandatory to record the meeting of the commission of medical specialists. Specialists in a medical institution are required to keep records of patient X-ray exposure. If a sick person needs to seek help from any specialized unit, then another form of the patient’s outpatient card is filled out there.

Filling rules

During the very first visit to a medical institution, the employee at the reception fills out the cover page of the card being issued. The title page contains detailed information about the patient. Entries in the outpatient medical record itself will be completed directly by medical specialists. Employees of the institution who have secondary medical education, are engaged in entering information into the register of patients who receive assistance.

The title page of the document indicates serial number cards of a sick person. If he has the right to a number of social services, then the letter “L” is indicated next to the number. During the appointment, the doctor must indicate the date of the visit. Also, the record should reflect the nature of the disease, various diagnostic and treatment measures carried out by specialists. When describing the disease, it is necessary to indicate the cause of its occurrence. For example, poisoning, accident, etc. All entries must be in chronological order. The doctor is required to make notes in the chart for each patient visit. Entry on the territory of the Russian Federation must be made in Russian (carefully and without any abbreviations). However, the names of drugs can be written in Latin letters. If the doctor made a mistake, it must be corrected immediately, and then this place in the text must be certified with a seal and signature. Each doctor has his own personalized seal, through which such actions are carried out. A sample outpatient card is presented below.

Some have a thicker card, some thinner. It all depends on the number of illnesses suffered and visits to specialists. A complete description of the disease picture and symptoms will help make the most correct diagnosis for a sick person. Sometimes it is necessary to consult several doctors of different specializations to make a diagnosis. In the vast majority of cases, information about a person’s tests is needed. All this data should be displayed in the medical record. Based on the conclusions of specialized specialists, the therapist will be able to make the correct diagnosis. It often happens that a person’s symptoms and pain can relate to several types of diseases at once. Therefore, it is necessary to exclude all ailments that a particular patient does not have.

Filling out the title page

The title page of the outpatient card form 025/U must be filled out in detail. To fill out, a person must present a passport to the employee if he is a citizen of Russia. If he is a sailor, then a sailor's certificate will do. Military personnel must present a military identification card Russian Federation. If a foreign citizen comes to the clinic, he has the right to present his passport or other identification document specified in International treaty. To visit a medical facility, a refugee must use an application as well as a refugee certificate. Stateless persons can apply to the clinic. For them, a mandatory document is a temporary residence permit.

The patient’s position and place of work must be indicated, but according to the person’s words (certificates from work are not required). Also, when registering an outpatient card, reception staff additionally request an INN and SNILS. Filling title page is not a complicated procedure, since there are hints about the information in each column in small print. To visit a primary care doctor, a person must provide information about their place of residence. Depending on the address, the patient is assigned to a specific doctor, as the territory is divided into streets. Sometimes a person goes to the clinic at his place of residence, and not at his place of registration. Such actions are not prohibited by law. A person can be registered in one city and live in another.

Electronic card

The electronic outpatient card has not yet been enshrined at the legislative level, but has already begun to function. The project is currently undergoing a pilot launch. An electronic card will be useful as it will allow you to store information on digital media. It will also help the coordinated work of various medical institutions, for example, a clinic and a hospital. Also, the electronic card will become an opportunity for the exchange of experience between specialists in the same field.

This service will be intended to store all information. Access can only be provided to persons authorized in this program. Also, the electronic medical record of an outpatient will contain all the information from the various medical institutions where this person went. In order for all information about a patient’s visit to the clinic to be stored in the system, it must be entered and recorded correctly.

The electronic card will contain the following information about the patient:

Anamnesis.
Days of visits to the clinic.
Diseases.
Surgical interventions.
Referrals to other medical institutions for diagnosis, treatment, etc. Their data.
Vaccination.
Diseases that have social significance.
Disability, the reason for its occurrence.

Because this information is personal, protection from unauthorized intervention is necessary. For this purpose it is used electronic signature employee.

Persons using the program:

Medical institutions, doctors, specialists. Employees of medical institutions who use the program are required to maintain medical confidentiality. They also enter information into the electronic map.
Patients. They only have access to their own medical records.
Other persons who may be provided with anonymized information for statistics, analysis, as well as for further planning of actions in the field of health care.

Card filling quality

The Law of the Ministry of Health of the Russian Federation does not prescribe the specific content of specialists’ notes in the outpatient card, but they all must have a certain sequence, be thoughtful and logical. To avoid comments from regulatory authorities, it is necessary to describe in detail all the patient’s complaints. It is necessary to indicate how many days have passed from the onset of pain and discomfort to the first visit to the doctor. The doctor is obliged to characterize the disease and indicate the person’s condition at the time of the visit. The diagnosis must be indicated in accordance with international classification all diseases. It is also important to describe the comorbidities that the patient suffers from.

The specialist’s record must include a list of medications for the treatment of a sick person, referrals to other specialists, examination results, information on the provision of sick leave, various certificates, as well as information on the availability of benefits for the patient.

In the same way, the specialist must fill out each patient visit correctly in the outpatient card. The card must also contain a signature indicating the person’s permission to undergo medical intervention or his refusal.

During the person’s return visit, the doctor must carry out the description in the same order. But it is also important to focus on the changes that occurred after the first visit of the sick person. Data on epicrises, consultations, and specialist opinions must be entered into the patient’s outpatient card. If a sick person dies, then a specialist must draw up a post-mortem epicrisis. It contains all the information about previously suffered diseases, surgical intervention, and the cause of death is stated. After this, a death certificate is issued to relatives this person. There are situations when it is difficult to determine the cause of death. Data from the map can help specialists figure this out.

Access to medical record

The information contained in the patient's outpatient record is a medical confidentiality. It is prohibited by law to disclose it, even if the person is dead. The fact that a person contacted a medical specialist is also not disclosed. The law allows certain persons provide information about patients without their knowledge. This is legal in the following cases:

The patient is a minor or unable to express his will.
Revealed infectious disease may cause an epidemic or lead to infection of people who have been in contact with the patient (for example, when sexually transmitted diseases are detected, everyone who has had sexual intercourse with the patient must be checked).
The patient's illness may affect the course of the criminal investigation.

However, lawyers, lawyers, employers, and notaries do not have the right to obtain information from the card without the permission of the patient himself.

Patient's rights

Patients and their legal representatives have the right to receive information from the card. Based on the data obtained, they can also receive advice from other specialists. The patient also has the right to receive copies of medical information, but only after a written application. Employees of medical institutions do not have the right to refuse to provide this information, since there are no grounds for this. In the application, the patient does not need to describe the reason or purpose in order to receive an extract from the outpatient record. There should be no charge for photocopying information. The employee must log the presence of the statement for reporting purposes. On at the moment the law did not provide for the issuance of the original outpatient card.

If for some reason a sick person cannot independently obtain a copy of the card, then he can write a power of attorney to another person. If employees refuse to provide information to the client, then these actions may entail administrative or criminal liability. There is also criminal liability for providing incomplete or false information to the patient.

Peculiarities

Many patients are dissatisfied with the new form of outpatient card and the established rules. They wonder why they can't get the original of their own card. The Ministry of Health clarifies that the outpatient card is intended only for medical workers and their colleagues, so that treatment is carried out professionally. The ordering in the database depends on its location in the place intended for it. If the patient needs information, the employee can always provide a copy of the data. A medical institution issues an outpatient card to a person when he or she moves and leaves the clinic. In other situations, the card must remain in the medical institution, since it is the property of the clinic.

Extracts

Every person has a medical card, since it is registered in the name of the baby immediately after his birth. Sometimes a person needs an extract from an outpatient card. This document is called “certificate 027/U”. This certificate is often requested in kindergartens, when a child enters school, and also at the workplace. At work this document may be asked to verify that the person was actually sick at some point in time.

Receiving the document occurs quickly. You need to seek help from a therapist or pediatrician in your area. Based on the information contained in the medical record, a certificate will be issued. In order for it to become valid, several stamps must be affixed. It can be difficult to obtain an extract from an outpatient card only if there are many diseases, since often the doctor must describe them all.

Sometimes receiving a certificate takes a couple of days. This may be due to the absence of specialists at the workplace to certify the extract. The stamp is affixed not by the attending physician, but by another employee. However, in many clinics there is a dedicated special officer or this procedure entrusted to the reception staff. They are always present at their workplace, so there are no problems with certifying the extract. A sample extract from the outpatient card is presented below.

Conclusion

A medical card is a mandatory document for all people who go to the clinic to receive medical care. The outpatient card form is created at the registry. To register, a person must submit necessary documents. The information contained in the medical record is a medical confidentiality. Patients cannot receive the original card in their hands. If necessary, the employee can make a photocopy of all data or issue an extract. If employees provide false or incomplete information, they will face administrative or criminal liability. Lawyers, attorneys and notaries do not have the right to obtain information from the outpatient card without the consent of the patient.

An electronic medical record has been launched, which will help systematize and combine all information about diseases and treatment of each patient.

The modern analogue of the traditional paper medical record has become the patient’s electronic medical record. It also records data about the visitor, all his visits to the clinic, indicates the results of examinations and other necessary information, but this data can be stored, supplemented and edited with greater convenience.

Electronic medical record of the patient as a way to systematize data

In the regions, a means of systematizing information received from all medical organizations in the region that use the mandatory system health insurance, is RIAMS - regional information and analytical medical system. Using this system, you can create a single electronic medical record for a patient. For example, if a patient is undergoing outpatient treatment, including dental treatment, the doctor can enter data about this into his electronic outpatient medical record. Another doctor in the region, in turn, will be able to review this information at any time if necessary. In addition, he can add new data to the card about services provided, recommendations for further treatment, about prescribed medications. All necessary information is added to the card, including treatment at a sanatorium, examination at a dispensary, and emergency medical calls.

Information in the electronic medical record must be correctly structured. The most important things are on the first page. Basic information includes:

date of birth
place of residence
compulsory medical insurance policy
connection to a clinic
benefits, if available.

The necessary medical information is also located on the first page: blood type, allergies, health group, cases of medical care and diagnoses. Separately, it should be noted that not all doctors can see data on some types of diseases. For example, information about mental illnesses and sexually transmitted diseases is open only to doctors of this specialization. However, there is a group of people who have unlimited access rights to all information; this is due, in particular, to the peculiarities of the work of emergency services and administrative workers of a medical organization.

Enhanced data about an individual clinic visit can also be obtained using the electronic medical record.

Using an electronic analogue of a paper card allows you to make the work of the clinic and each individual employee more productive, thanks to the proposed tools. The convenience of the new way of maintaining documentation is not only in how information is stored and displayed, but also in how new data is entered. For example, when making a diagnosis, it is not entered into the chart manually, but is selected from a menu; this avoids synonymy, when specialists call the same disease differently. The options on the menu are given in accordance with the international classification of diseases. This also applies to medicines, errors in their names can also be avoided by using an electronic card.

Since the data in a single electronic medical record is organized and entered using a specific template, significant time savings occur. When filling out any column, after entering two or three characters, the program itself suggests a possible continuation, without having to complete long terms manually.

Of course, in a single electronic medical record, it is possible to take into account the unique course of the disease in a particular patient, because each case is unique in its own way, and each doctor can characterize it in his own way. Especially for this, the program has the ability to add options in the drop-down menu yourself, in accordance with the frequency of use of a particular wording.

The specific wording that is recommended to be added to the glossary may not apply to unique occasion, but, on the contrary, to the most frequency one. For example, it is known that people most often turn to a therapist because of a cold or acute respiratory viral infection. In order not to waste time filling out the card each time, it is enough to create the appropriate template once and use it every time during an inspection. This will avoid the tedious work that forces the doctor to describe the same symptoms every time.

A phrase or term that is added to the dictionary can be assigned to a specific field, then only those that correspond to the subject of the field will appear in the proposed options. For example, in the “Anamnesis of illness” column, only wording will be offered that corresponds to possible answers obtained by asking the patient about his illness.

Maintaining an electronic medical record makes the process of filling it out more convenient. And since the use of templates simplifies typing, the time spent on maintaining a map is significantly saved (by 70-80%). The time saved can be spent on the most important thing - interacting with the patient. This will optimize the work process in the clinic and improve the quality of service.

In addition, an electronic medical care record allows the doctor to avoid possible errors. After all, an electronic card is, first of all, access to a database that contains information about the patient, the drugs that were prescribed to him, and the results of his tests. All this can be used for a more detailed analysis of the patient’s condition and to make the correct diagnosis in accordance with federal and regional standards.

Maintaining an integrated electronic medical record

An integrated electronic medical record is a type of medical electronic record in which all data about one patient is combined in a common document. Several clinics can familiarize themselves with the contents of this document and make changes and additions to it.

An integrated electronic medical record (IEMR) is a combination of electronic personal medical records of one person; their collection and further use is carried out by medical institutions.

Several medical institutions or a health care management body can organize the maintenance of common electronic medical records.

Before introducing a new type of card, these organizers must outline how to manage the system. In the future, they will determine who can access documents, be responsible for the safety of data, and the possibility of exchanging information between medical organizations, for the interaction of the system with other products and systems with which the doctor works.

The main task set by an organization implementing electronic records is to improve the quality of patient care through competent management of medical data. This data should be supplemented during the treatment process and then stored in a place accessible to medical workers.

The process of maintaining an electronic medical record is regulated by an integrated electronic medical archive, which tracks the receipt of new information, its processing, further storage and transfer to medical organizations.

Formation of the document and entering new data into it is not the responsibility of the archive; this is the responsibility of the clinics and their employees. In order for the archive to provide the most complete information about the patient, it is necessary that the employees entering data into the documents take this process seriously, and not only add new information, but also transferred old data stored in paper medical records.

In order for the information in the electronic medical record to correspond to reality, it is necessary to strictly ensure that it is possible to clearly understand which patient the record relates to and who entered the data about him. Data must be entered taking into account the general rules.

Electronic medical record is available:

Medical personnel, within the framework of Art. 13 “Compliance with medical confidentiality” of the law “On the fundamentals of protecting the health of citizens in the Russian Federation” and Art. 10 “Special categories of personal data” of the Law “On Personal Data”
The patient, taking into account Art. 22 “Information about the state of health” of the law “On the fundamentals of protecting the health of citizens in the Russian Federation” and Art. 14 “The right of the subject of personal data to access his personal data” of the Law “On Personal Data”.

Data from the electronic medical record is not destroyed, it is stored in the system for a long period, and access to it is limited only after the death of the patient, then it is transferred to the archive.

Training employees to maintain electronic medical records

Not all innovations are accepted with enthusiasm by employees; this also applies to the implementation of an electronic patient medical record. With its advent, medical workers will need to learn how to maintain documentation electronically, which may especially cause rejection among older employees.

However, experience shows that, despite the first, possibly negative reaction, employees quickly get used to it, and after a few months more than half of them begin to maintain documentation electronically. And after a year, the entire clinic is working with electronic medical records.

To properly introduce a new card format into everyday use, it is better to do this gradually. As the implementation of electronic medical records progresses, employees will find many benefits in them, for example, the incidence of loss of records containing important information, which cannot be restored because it is not duplicated anywhere.

When it was not possible to provide a computer workplace each doctor, nurses had to continue to maintain documents in paper form, and then transfer them to employees who entered the information into the regional information and analytical medical system. But some documents, although insignificant, were lost, information was sometimes distorted when transferred from one employee to another. Later, when technology became more accessible, doctors and nurses began to maintain an electronic medical record immediately during a patient’s visit. This format is of better quality than the previous one; when using it, fewer inaccuracies are allowed.

It is possible that at the first stage of introducing electronic medical records, employees will need additional motivation in the form of bonuses amounting to up to 10% of wages. If clinic staff have difficulties working with equipment, then begin implementing new form document management should be done by those for whom working on a computer is not difficult. Most often, these are younger employees who are happy to take on something new. Very soon, they will experience the convenience of an electronic patient record, which provides comprehensive patient data and facilitates the process of filling out documents. In addition, the paper document may be lost or damaged, forgotten in another hospital. And the electronic one, if necessary, can be easily printed.

Clinic staff were among the first to start working with electronic medical records. The system performs all the functions they need: it generates data about the patient’s visit and what treatment or additional examination the doctor prescribed.

For hospital staff, maintaining an electronic form of the card also turned out to be convenient; they could already use the data entered by clinics, as well as add their own records, for example, about operations performed.

Doctors from different clinics can transfer patient data to each other using an electronic medical record. This is especially important when we're talking about about the results of x-ray and laboratory tests. If you save information about these results in a chart that is available to all doctors interacting with a given patient, the number of repeat tests is reduced. Thus, x-rays are repeated 50% less often, and tests are taken 80% less often.

You might be interested

What is an outpatient card? You will learn the answer to this question from this article. In addition, your attention will be presented with information about why such a document is being created, what items it includes, etc.

General information

An outpatient card is a medical document. In it, attending physicians keep records of the prescribed therapy and medical history of their patient. It should be noted that such a card is one of the main documents of a patient who is undergoing treatment and examination in an outpatient and outpatient setting. The form of the medical record is the same for everyone. This document is created for each patient upon his first visit to the hospital.

Medical record and its role in practice

An outpatient card, first of all, serves as the basis for any legal actions (if any). Moreover, correctly filling out a patient’s medical history has great educational significance for the doctor, as it strengthens his sense of responsibility. It should also be noted that this document is very often used in insurance cases (in case of loss of health of the insured person).

Incorrectly completed cards

If an outpatient’s medical record was filled out inaccurately or was lost by the registry, then patients can make justified claims against the institution. By the way, in some clinics there is such a practice as intentional loss. Typically, this happens with poor clinical outcomes, errors in prescription medicines and procedures, etc.

One of the means of improving the safety of outpatient records is the introduction of their electronic versions. But this method There are two sides: thanks to such documents, you can quite easily track the sequence of their changes, however, the issued electronic card does not have any legal force.

The outpatient medical record includes forms for immediate and long-term information. Let's consider their content in more detail.

Operational information forms consist of formalized inserts for recording the patient’s first visit to the doctor, as well as for patients with influenza, sore throat and acute respiratory disease. In addition, they contain inserts for return visits for the consulting committee. Such forms are filled out as the patient visits the doctor at home or during an outpatient appointment, and are glued to the spine of the card.
Long-term information forms contain warning marks, information about preventive examinations, sheets for recording already specified diagnoses and sheets for prescribing any narcotic drugs. These inserts are usually attached to the card cover.

Basic principles of charting

An outpatient card is required for:

descriptions of the patient’s condition, treatment outcomes, therapeutic and diagnostic measures and other information;
maintaining the chronology of events that influence organizational and clinical decision-making;
reflections of physical, social, physiological and other factors that influence the patient throughout the pathological process;
understanding and compliance by the attending physician with all legal nuances its activities, as well as the significance of medical documentation;
recommendations to the patient after completion of the examination and completion of treatment.

Requirements for card registration

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

Each entry is signed only by the attending doctor with his full name deciphered. Entries that have nothing to do with the care provided to the patient are not permitted. All notes in the medical record must be thoughtful, logical and consistent. Special attention is given to those records that were kept in complex diagnostic cases, as well as in the provision of emergency care.