to the order of the Ministry of Health of the Donetsk People's Republic
02.09.2016 № 1059
INSTRUCTIONS
on filling out the primary accounting documentation form No. 066/u
“Card of a patient who left the hospital No. ______”
1. This Instruction determines the procedure for filling out the form of primary statistical accounting documentation No. 066/u “Card of a patient leaving the hospital No.___” (hereinafter referred to as form No. 066/u).
2. Form No. 066/u is drawn up on the basis of primary accounting documentation forms No. 003/u “Medical record of an inpatient patient” (hereinafter referred to as form No. 003/u), No. 003-1/u “Medical record of termination of pregnancy” (hereinafter referred to as form No. 003-1/u), No. 096/u “History of childbirth” (hereinafter referred to as form No. 096/u), No. 097/u “Map of the development of a newborn” (hereinafter referred to as form No. 097/u), and is a document containing information about the patient (discharged or deceased) who left the hospital.
3. In form No. 066/у, all points must be filled out. The exceptions are paragraph 32, which is filled in in the event of the death of a hospitalized person, paragraphs 2 - insurance policy, 3 - type of payment and columns 8, 9, 10 of paragraph 30 - patient movement through departments are filled out after introduction in Donetsk People's Republic compulsory health insurance systems.
4.p.1 Patient code is an identification number patient or other code accepted in the health care facility.
5.p.2. Insurance policy. If the type of payment is medical insurance, then the details of the insurance policy and the insurer (insurance company, territorial compulsory medical insurance fund, TFOMS branch) are recorded with the obligatory indication of the code of the territory in which the insurer is located according to the current classifier.
6.p.3. Type of payment: compulsory medical insurance – 1, budget – 2, paid services– 3, incl. VHI – 4, other – 5, the corresponding details are underlined or circled.
7.p.13. Social status is noted by circling the corresponding position and entering a number in the appropriate cell.
8.p.15. Category of benefits. To be completed for patients belonging to the category of the population entitled to preferential benefits medicines and products medical purposes: The corresponding position is marked.
9.Points 1-8 of form No. 066/у are filled out nurse admission department simultaneously with filling out form No. 003/u, or No. 003-1/u, or No. 096/u, after which form No. 066/u is inserted into one of the forms noted above and stored in the department until the patient is discharged from the hospital or death sick.
2
Continuation of Appendix 16
Form No. 066/у for a newborn is filled out in maternity ward hospital along with the newborn development card - registration form No. 097/u (for all newborns born sick, sick, or dead).
10. Form No. 066/у is filled out by the attending physician simultaneously with the entry of the epicrisis in the primary accounting documentation specified in paragraph 2 of this Instruction for all patients who left the hospital (discharged or died), including for postpartum women who were discharged after normal birth.
11. Form No. 066/u indicates the name of the hospitalization department (item 20), the urgency of hospitalization (item 23), the duration of hospitalization (item 24), hospitalization for this disease in this year: 1 – for the first time, 2 – again, 3 – again up to 30 days from the date of discharge after a previous hospitalization for the same disease (item 25), result of treatment (item 27).
12. In paragraph 28, the date of discharge of the patient from the hospital is noted, and in the event of his death, the date of death.
13. When transferring a patient from one department to another of the same hospital, form No. 066/u is filled out in the department from which the patient left.
14. In form No. 066/u, for patients who were in the hospital for injuries and poisonings, a note must be made (clause 26) regarding the type of injury: industrial, household, street, road traffic, school, sports, etc.
15.If the patient has side effect medicine the attending physician notes this in paragraph 31 of form No. 066/y, the manifestation of a side effect as “the main diagnosis”, or “complications”, or “ accompanying illnesses” and highlights them in red.
In such cases, the attending physician or medical statistician double codes this item according to the International Statistical Classification of Diseases and related problems healthcare of the Tenth Revision (hereinafter referred to as ICD-10): the main diagnosis and complication are coded: the range of headings A00-R95, T80.5.6, T88.2, T88.6 and others, including headings Y40 - Y59. In cases where several diagnoses of diseases are noted in form No. 066/u, in reporting form No. 20 “Report of a healthcare institution for the year 20___,” table 3220 “Composition of patients in the hospital, timing and result of treatment (number)” is filled in, data on the patient will be noted according to the disease that was the main reason for hospitalization. Data on the timing and outcome of treatment of patients who were transferred to other hospitals are not noted in table 3220 “Composition of patients in the hospital, timing and outcome of treatment (number)” of form No. 20; are entered into table 3221 of form No. 20.
3
Continuation of Appendix 16
16. In paragraph 32 “In the event of the death of a patient”, a record is made in accordance with paragraph 11 of the medical death certificate (form of primary accounting documentation No. 106/u “Medical death certificate”, which indicates pathological conditions that led to the immediate cause of death, and other significant conditions that contributed to death.
17. In paragraph 33, surgical operations are included in chronological order, the operation code is entered according to the classifier of surgical interventions (based on this data, tables 3500 " Surgical work hospital", 3501, 3502 and 3600 "Emergency surgical care for patients who left the hospital during the reporting period" form No. 20).
Data on postoperative complications are entered in column 6, their code is gr. 7. Added column No. 9 – “Complications during anesthesia caused by anesthetic measures during surgery.” In this column you should put the number of the corresponding complication: cardiac arrest, acute heart failure - 1, acid aspiration syndrome (aspiration pneumonitis) - 2, unsuccessful attempts or difficulties during tracheal intubation - 3, allergic reactions, including anaphylactic shock– 4, accident while providing assistance – 5, others – 6.
18. When filling out paragraph 34, only data on the examination that was carried out during the treatment of the patient in this hospital are noted.
19. In paragraph 35 defects prehospital stage are marked by entering the corresponding number in the box.
20. In form No. 066/u, the last name, first name and patronymic of the attending physician (legible) and his signature must be indicated.
21. If form No. 066/у is maintained in electronic format, it must include all the information contained in the approved paper version.
22. The shelf life of form No. 066/у is 5 years.
by filling out form 066/u-p
“STATISTICAL CARD of a patient continuing treatment”
A STATISTIC CARD of a patient continuing treatment (hereinafter referred to as the Stat Card) is filled out for all patients who are on long-term treatment(more than 1 calendar month) in a drug treatment, tuberculosis, oncology hospital and for patients receiving hemodialysis, on the last day of the calendar month. At the end of the course of treatment (when the patient is discharged from the hospital), a statistical card of the person leaving the hospital corresponding to the profile is filled out (form 066/у, 066-1/у, 066-2/у, 066-4/у), in which the medical services provided are entered and medications only for the last unpaid period. Name of the hospital: the full and short official name of the medical organization is allowed. OKPO code: filled in based on the organization’s statistical map.
Statcard number: must match the number medical card inpatient.
Points 1-6 and 8: data from identification documents and from the words of the patient.
Clause 7 “Registration medical number”: intended for planned individual medical records.
Points 9-22: are filled out on the basis of the medical record of the inpatient (form No. 003/у). The code for the type of department and bed profile is assigned from the directory of the Ministry of Health of the Republic of Kazakhstan. ICD-10 is used to code diagnoses.
Clause 16: The surgical operation code is assigned from the directory of the Ministry of Health of the Republic of Kazakhstan. If there were several surgical interventions, then the “Main operation” is highlighted, which must be filled out first, regardless of the date of the operation in relation to other operations.
Clause 17: The MEP (medical and economic protocol) code is assigned from the directory of the Ministry of Health of the Republic of Kazakhstan in accordance with the current rules
Item 18: to be completed based on the medical record of the inpatient
Item 19: to be completed if the patient’s treatment continues for more than 1 calendar month in a drug treatment, tuberculosis, oncology hospital and for patients receiving hemodialysis.
Clause 20: The list of services and medications provided is filled out in accordance with the current rules and reference books. Only services external to the clinical department (laboratory, x-ray, ultrasound, etc.) are subject to registration. Services included in the scope of work of the clinical department (injections, anthropometry, blood pressure measurement, examination by a doctor, etc.) are already included in the services of the clinical department and do not need to be filled out. If there is not enough space to enter data on the services and manipulations performed, and medications used, it is necessary to expand the Sheet of Services Rendered with an additional insert.
Item 21-22: Last name, first name, patronymic, signature of the attending physician and head of the department. Doctors' codes are entered in accordance with the internal directory of the medical organization.
Note: the form is filled out and printed in accordance with the organization’s profile
Azirleushiler nazaryna – bagdarlamalyk zhasaktama klinikalyk more kyzmetterin kyzmetter turі buynsha shygaruy tiіs
Attention developers - software should cull clinical department services by type of service
Appendix 7
Toorder Minister of Health
Republic of Kazakhstan
A4 formats
A4 format
| KUZHZ boyinsha uyym codes Organization code according to OKPO _____________________________________ |
||
| Kazakhstan Republics Densaulyk saktau ministerligi Ministry of Health Republic of Kazakhstan | Kazakhstan Republics Densaulyk saktau ministerin 2011 zhylgy “11” mamyrdagy No. 280 buyrgymen bekitilgen No. 066-5/e nysandy medicinalyk kuzhattama |
|
| Uyimnyn atauy (Name of organization) | Medical documentation. Form No. 066-5/у approved by order of the Minister of Health of the Republic of Kazakhstan dated May 11, 2011 No. 280 |
|
HOSPITAL SHYKAN ADAMDARDY STATISTICS MAPS
"
STATISTICAL MAP OF DEPARTURES FROM HOSPITAL
(pregnant women, postpartum women and newborns (stillborns)
1. Tags (Last name)_________________________________________________________________________________________________________
Aty (Name)________________________________ Әkesinin aty (Patronymic)__________________________________________________________
2. Tugan kuni (Date of birth) /______/______/__________/
kk/aa/zhzhzh (dd/mm/yyyy)
3. Ulty (Nationality) ______________ 4. Turgyny (Resident): kalanyn (city) – 1, auldyn (village) – 2
5. ZhSN (IIN)
6. Medical services
(Registration medical number)
7. Mekenzhayi (Place of residence)_______________________________________________________________________________________________
________________________________________________________________________________________________________________________
ate, bald, akimshilik audany (country, region, administrative district) eldi meken, koshe, үy, peter ( locality, street, house, apt.)
8. Aleumettik martebesi (Social status): 1- kyzmetker (employee), 2- zhumysker (worker), 3 - aul sharuashylygynyn zhumysshysy (employee Agriculture), 4 - zeinetker (pensioner), 5 - okushy (student), 6 - үy sharuasyndagy әyel (housewife), 7 - zheke enbekpen ainalysatyn tulga (person engaged in self-employment), 8 - tabynushy (clergy minister), 9 - zhumyssyz (unemployed), 10-basqalar (other).
9. Zhenildik categories (Category of benefits): bala kuninen mugedek (disabled from childhood) – 1, auras boyinsha mugedek (disabled by illness) – 2, saule aserin algan adam (person exposed to radiation) – 3, ҰOSҚ tenestirilgen a lady (person equivalent to UVOV) - 4, enbek mugedegi (disabled worker) - 5; Konys audarushy (displaced person) – 6; basqalar (other) – 7.
10. Patient bagytaldy (Patient referred): BMSC (PHC)-1, DEEK (KDP)-2, Ozi karaldy (referred herself)-3, zhedel zhardemnen (ambulance)-4, baska hospital (another hospital)-5, basqalar (other)-6, (astyn syzyңyz (underline).
Code and name of the referring medical facility: _______________________________________________________________________________________________
14. Aurukhanaga zhatkyzu turi (Type of hospitalization): 1 - zhosparly (planned), 2 - shұgyl tүrde auyrgannan bastap 6 sagattyn іshіnde (emergency in the first 6 hours from the onset of the disease), 3 - shұgyl tүrde 7- 24 sagattyn ishinde (emergency during 7- 24 hours), 4 - shugyl turde 24 sagattan keyin (emergency after 24 hours)
15. Wasps auru saldarynan biylgy zhyly auruhanaga zhatuy (Hospitalization in a given year for this disease):
birinshi ret (for the first time) – 1, kaytalap (again) – 2
16. Kelіp tusken kezdegi diagnoses (Diagnosis upon admission):___________________________________________________________________________
10 -HAZH codes (code according to ICD-10)
17.1. Bosanu orny (place of birth): 1-hospital (in a hospital), 2-uyde (at home), 3-baska zherde (in another place)
17.2. Algashky ret zhukti bogan
(Primigravida): iә (yes)-1 zhoq (no)-2
17.3 Bosandyru sipaty (Nature of childbirth): 1- physiology (physiological), 2- pathology (pathological)
17.4 Bosanu sana (Which are the births) ________
17.5 Zhuktilikti uzu nemes bosana sotindegi zhuktilik merzimi, apta (Greatness period at the time of termination of pregnancy, birth or death, weeks) ____________________
17.6 Abortion turleri (Types of abortion): 1 - ozdiginen (spontaneous), 2 - 12 aptaga deyingi medical abortion (medical abortion up to 12 weeks), 3 - kishi abortion (mini-abortion), 4 - aleumettik korsetimder boyynsha abortion (abortion for social indications), 5- medical korsetimder boyinsha abortion (abortion by medical indications), 6- qylmystyk zholmen zhasalgan abortion (criminal abortion).
17.7. Medical abortion (Medical abortion)
17.8 Zhana Tugan nareste turaly malimetter: (Information about the newborn)
| Tuu kuni uakyty Birth | Bala there The baby was born | Balanyin zhynysy | ay-kuni zhetip/shala ***
| Here you go Physical Child development At birth | He was born (vaccination) | Shyguy Exodus **** | Tuuyna katysty olim (Type of death in relation to childbirth)***** | HAZH-10 diagnoses Diagnosis ICD-10 | Atau diagnosis Name Diagnosis |
||
| Salmagy Weight (g) | June date | ||||||||||
| Boys Height (cm) | BCG | ||||||||||
| | IPV (OPV) | ||||||||||
| Bass Olshemi Head circumference (cm) | hepatitis | ||||||||||
| Salmagy Weight (g) | June date | ||||||||||
| Boys Height (cm) | BCG | ||||||||||
| Keude Olshemi Chest circumference (cm) | IPV (OPV) | ||||||||||
| Bass Olshemi Head circumference (cm) | hepatitis | ||||||||||
| Salmagy Weight (g) | June date | ||||||||||
| Boys Height (cm) | BCG | ||||||||||
| Keude Olshemi Chest circumference (cm) | IPV (OPV) | ||||||||||
| Bass Olshemi Head circumference (cm) | hepatitis | ||||||||||
* 1- tiri (alive), 2-oli (dead)
** 1-er (male), 2-ayel (female), 3-anyktalgan zhok (not defined)
*** 1 - ayy-kuni zhetip (term), 2 - shala (premature), 3 - merzimine asyp (term)
**** 1 - discharged; 2 - hospitalized for stage 2 of nursing; 3 - died in the maternity hospital; 4th-born
***** 1-tuylganga deyin (before childbirth) (antenatally), 2-tuylganga deyin (before childbirth) (antenatally), 2-tuylganga deyin (during childbirth) (intranatally), 3-tuylgangan keyin (after childbirth), 4-belgіsіz (unknown)
18. Zhas nareste perzetkhanada emdeuden өtti (The newborn was treated in the maternity hospital)
_______________________________________________________________________________________________________________________
19. Aurukhanaga zhatkyzu kuni men uakyty (Date and time of hospitalization) ______/______/______ ______/______
kk/aa/zh (dd/mm/yy) agats, min (hours, min)
20. Shykkan (kaytys bolgan) kuni men uakyty: (Date and time of discharge (death))______/______/______ ______/______
kk/aa/zh (dd/mm/yy) sagaty, min (hours, min)
21. Өtkizgen tosek-kunderi (Bed days spent) ________________________________________________________________________________
atauy (name)
MINISTRY OF HEALTH OF THE RUSSIAN FEDERATION
On approval of instructions for filling out the registration form
medical documentation
In order to unify approaches to filling out medical records of medical institutions that use registration forms in their work,
I order:
1. Approve:
1.1. Instructions for filling out registration form N 039/u-02 “Record of medical visits in outpatient clinics, at home” (Appendix No. 1).
1.2. Instructions for filling out registration form N 007/u-02 “Sheet for daily recording of the movement of patients and the bed capacity of a 24-hour hospital, day hospital at a hospital institution” (Appendix No. 2).
1.3. Instructions for filling out registration form N 016/u-02 “Summary statement of the movement of patients and beds by hospital, department or profile of beds in a 24-hour hospital, day hospital at a hospital institution” (Appendix No. 3).
1.4. Instructions for filling out registration form N 007ds/u-02 “Sheet for daily recording of the movement of patients and the bed capacity of a day hospital at an outpatient clinic, hospital at home” (Appendix No. 4).
1.5. Instructions for filling out registration form N 066/u-02 “Statistical card of a person leaving a hospital around the clock, a day hospital at a hospital institution, a day hospital at an outpatient clinic, a hospital at home” (Appendix No. 5).
2. Instructions for filling out accounting forms: N 039/u-02 “Record sheet of medical visits in outpatient clinics, at home”, N 007/u-02 “Sheet of daily records of the movement of patients and bed capacity of a round-the-clock hospital, day hospital at a hospital institution", N 016/u-02 "Summary sheet of the movement of patients and beds by hospital, department or profile of beds of a round-the-clock hospital, day hospital at a hospital institution", N 007ds/u-02 "Sheet of daily records of the movement of patients and bed capacity of a day hospital at an outpatient clinic, a hospital at home", N 066/u-02 "Statistical card of a 24-hour hospital stay, a day hospital at a hospital facility, a day hospital at an outpatient clinic, a hospital at home" enter into effective from 12/01/2003.
3. Entrust control over the implementation of this order to Deputy Minister R.A. Khalfin.
Minister
Yu.L.Shevchenko
Appendix No. 1. Instructions for filling out registration form No. 039/u-02 “Record of medical visits in outpatient clinics, at home”
Appendix No. 1
“The register of medical visits in outpatient clinics, at home” (hereinafter referred to as the “Vedomost”) is filled out by all doctors of medical institutions who conduct outpatient visits to patients in the clinic and at home, incl. and leading only consultation.
A visit is a contact between a patient and a doctor for any reason, followed by an entry in the chart. outpatient(prescription of treatment, records of follow-up, diagnosis and other records based on observation of the patient).
The following visits are subject to recording:
- doctors of any specialty conducting outpatient visits, including consultations (therapists, pediatricians, surgeons, obstetricians-gynecologists, urologists, otolaryngologists, etc., including the head of the department);
- psychotherapists when conducting group classes(the number of visits is taken into account according to the number of patients studying in the group);
- doctors of health centers, shop therapists, obstetricians-gynecologists and others who receive appointments at health centers during hours specially allocated for outpatient appointment;
- doctors providing medical care on days specially designated for outpatient visits, when traveling to other medical institutions ( district hospitals, local hospitals and outpatient clinics, paramedic and obstetric centers);
- visiting a patient or a relative of a patient to re-issue a prescription (oncopathology, diabetes and etc.);
- infectious disease doctors conducting door-to-door visits during an outbreak infectious diseases, examinations of contacts in the outbreak (family) of an infectious disease.
Note: Visits by a patient to the same doctor during the day are counted as one visit.
- consultations of outpatients by hospital doctors, for registration of which enter f. N 039/у-02 on a general basis, separately for each medical specialty;
- cases of provision medical care in the admission departments of hospitals for patients who are not subject to hospitalization, for the recording of which, in addition to the entry from the “Register of admission of patients and refusals of hospitalization” (f.N 001/u), a f. N 39/у-02;
- consultations by doctors of clinics with patients undergoing treatment in a hospital.
In the hospital nursing care visits are shown only if there is a doctor's position.
Preventive examinations of children in preschool institutions, schools, preventive examinations of the population, including periodic examinations of workers at industrial enterprises, employees of children's, communal and other institutions, are included in the number of visits, regardless of whether they are carried out within the walls of the clinic or directly at enterprises (institutions) ), if there is a corresponding record of the work performed in the outpatient medical record (form N 025/u), the history of the child’s development (form N 112/u), the child’s medical record (form N 026/u).
The following are not counted as doctor visits:
Cases of provision of medical care by personnel of ambulance and emergency medical care stations (departments);
- examinations in X-ray rooms, laboratories, etc.;
- cases of medical assistance in the classroom physical culture, educational and sports events;
- consultations and examinations conducted by clinical expert commissions (CEC);
- visits to doctors in auxiliary departments (offices).
Note:
Visits to doctors in auxiliary departments and offices are taken into account only if the patient is “managed”: treatment is prescribed with an entry in the outpatient card, during treatment monitoring and after completion of the prescribed course of treatment ( radiation therapy, physiotherapeutic, physical therapy, endoscopy.
Visits regarding illnesses should include:
Visits when the applicant has been diagnosed with a disease;
- visits for treatment;
- visits to the dispensary during the period of remission;
- visits by patients in connection with registration for VTEC, health resort card opening and closing a certificate of incapacity for work, obtaining a certificate of illness of a child, referral for an abortion for medical reasons, regarding the pathology of pregnancy, after abortions for medical reasons, as well as for consultations with specialists, even if the doctor does not find any pathology in his specialty .
To visits from for preventive purposes should include:
Visits regarding examinations upon admission to work, study, etc. preschool, when sent to recreational institutions; inspections of contingents subject to periodic inspections; examinations of the population during annual medical examinations; inspections when deciding whether to conduct preventive vaccinations(provided that during the examination the patient does not have any diseases);
- visits to pregnant women normal pregnancy; visiting women seeking a referral for a medical abortion; regarding medical abortions performed in outpatient setting, applications contraception; after medical abortions performed in a hospital, etc.;
- patronage visit healthy children of the first year of life, the work of doctors of draft commissions, repeated rounds of infectious disease doctors during an outbreak of infectious diseases.
If the doctor, when conducting preventive examination only suspected a disease, but did not make a diagnosis and referred the patient to the appropriate specialist for diagnosis; a visit to the doctor who performed the examination should be counted as a visit for preventive purposes. A visit to a consulting specialist in the event of a diagnosis should be counted as a visit for a disease.
Visit to the middle medical personnel:
Visits by nursing staff are subject to recording in cases of self-administration in medical outpatient clinics, medical and paramedical health centers, and first-aid posts, including visits regarding procedures. A visit is counted as one if a procedure is performed at the same time when visiting for a disease. Visiting patients during the day to the same medical worker counts as one visit.
How to fill out the form:
Column 1. "Date". The column contains the numbers (days) of the reporting month.
Column 2. “Number of visits to the clinic, total.” The number of visits to the clinic for the corresponding date by all patients (urban, rural and any age) both for diseases (column 6) and for preventive purposes is indicated, that is, information from column 9 is included in column 2.
Column 3. “Number of visits to the clinic by rural residents.” The number of visits to the clinic by rural residents both for diseases and for preventive purposes is indicated (from column 2).
Column 4. “Number of visits to the clinic, including those aged 0 to 17 years.” The number of visits by persons aged 0 to 17 years (from column 2) both for diseases and for preventive purposes is indicated.
Column 5. "Number of visits to the clinic, including those aged 60 years and older." The number of visits by persons aged 60 years and older (from column 2) both for diseases and for preventive purposes is indicated.
Column 6. "From total number visits to the clinic for diseases, total." The total number of visits to the clinic for diseases is indicated (from column 2).
Column 7. “Out of the total number of visits to the clinic for diseases, including those aged 0 to 17 years.” The number of visits to the clinic by patients aged 0 to 17 years for diseases is indicated (from column 6).
Column 8. “Out of the total number of visits to the clinic for diseases, including those aged 60 years and older.” The number of visits to the clinic by patients aged 60 years and older for diseases is indicated (from column 6).
Column 9. “Preventive”. The number of all visits to the clinic for preventive purposes is indicated (from column 2).
Column 10. “Number of home visits, total.” The number of all home visits is indicated, both for diseases and for preventive purposes.
Column 11. “Of the total number of home visits, visits for illnesses, total.” The number of home visits for diseases is indicated (from column 10).
Column 12. “Of the total number of home visits, visits regarding illnesses to persons aged 0 to 17 years.” The number of home visits to patients aged 0 to 17 years regarding diseases is indicated (from column 11).
Column 13. “Of the total number of home visits, visits regarding illnesses to children aged 0 to 1 year.” The number of home visits to children aged 0 to 1 year inclusive for diseases is indicated (from column 12).
Column 14. “Of the total number of home visits, visits for illnesses to persons aged 60 years and older.” The number of home visits to patients aged 60 years and older for illnesses is indicated (from column 11).
Column 15. “Of the total number of preventive home visits to persons aged 0 to 17 years.” The number of home visits for preventive purposes to patients aged 0 to 17 years is indicated.
Note: The total number of home visits for preventive purposes is calculated as the difference between columns 10 and 11 (column 10 - column 11)
Column 16. “Of the total number of preventive home visits to children aged 0 to 1 year.” The number of home visits for preventive purposes to children aged 0 to 1 year inclusive is indicated (from column 15).
The sum of the numbers in column 2 (“Number of visits to the clinic, total”) and column 10 (“Number of visits at home, total”) are distributed by type of payment in columns 17 to 20 “Number of visits by type of payment.” The corresponding columns indicate:
Column 17. "Compulsory medical insurance" - Visits for which payment is made by compulsory medical insurance.
Column 18. “Budget” - Visits financed from the budget.
Column 19. “Paid” - Visits paid for by patients.
Column 20. “VHI” - Visits paid for by VHI.
The sum of the numbers in columns 17 to 20 (17+18+19+20) may be equal to the sum of the numbers in columns 2 and 10 (2+10), or less by the number of visits for which payment is made through another source of financing.
Appendix No. 2. Instructions for filling out registration form No. 007/u-02 “Sheet for daily registration of the movement of patients and the bed capacity of a 24-hour hospital, day hospital at a hospital institution”
Appendix No. 2
Work accounting inpatient institutions both urban and rural, regardless of their specialization, are kept according to the “Sheet of daily registration of patients and beds in a 24-hour hospital, day hospital at a hospital institution” (record form N 007/u-02).
Registration form N 007/u-02 is the primary accounting document on the basis of which daily records are kept of the movement of patients and the use of beds in the department or hospital. This accounting form allows you to monitor changes in bed capacity and the movement of patients. In addition, it provides the opportunity to regulate the admission of patients in the hospital, since columns 20 and 21 of form N 007/u-02 indicate the availability of available beds.
A sheet for recording the movement of patients and beds is filled out in each department allocated within the hospital in accordance with the estimate and orders of the higher health care authority.
Information on departments containing narrow-profile beds allocated by hospital order (for example, oncology beds as part of a surgical or gynecological department, beds for children in the neurological department, etc.) are shown in the form as follows: the first line contains information on the number of beds and the movement of patients in the department as a whole (including information on beds of narrow specialties), and the subsequent lines contain information about beds and the movement of patients in selected narrow specialties. When filling out lines related to narrow specialty beds allocated in a department, the movement of patients with diseases corresponding to the profile of the allocated beds in this department is shown, regardless of which beds in this department they were on. For example, in the surgical department, by order of the hospital, 3 beds were allocated for urological patients; in fact, on some days there were not 3, but 5 or more urological patients in the department - the movement of these patients is shown by urological beds. At the same time, patients with urological diseases could be hospitalized in other departments, which did not have urological beds. Information about these patients is shown according to the beds of the department in which they were placed, and is not summarized with information about urological patients lying in the department that had urological beds.
In cases where a hospital order has made a temporary or permanent repurposing of beds, information in the form (Column 3) about the actually deployed beds is shown according to the new bed profile. For example, if the beds therapeutic department are repurposed into beds for infectious patients, then column 3 shows infectious beds.
The number of beds does not include beds for mothers in children's wards, beds for newborns and Rakhmanov beds in maternity wards.
Column 3 shows the beds actually deployed within the budget, including free beds not occupied by patients, and beds temporarily closed due to repairs, quarantine and other reasons in accordance with the hospital order. This number does not include additional beds located in wards, corridors, etc. due to the department being overcrowded.
From the number of beds shown in column 3, column 4 includes beds that are temporarily closed due to repairs and other reasons.
When filling out information about the movement of patients, column 5 (patients) shows the total number of patients in the department at 9 a.m. of the previous day, including patients occupying additional beds.
Columns 5-17 show information about the movement of patients over the past day, from 9 a.m. of the previous day to 9 a.m. of the current day (about the number of patients who were admitted and received, including from day hospitals; transferred from department to department; discharged, including in day hospitals; deceased).
Column 18 shows information about the number of patients in the department at 9 a.m. of the current day, and column 19 shows information about mothers with sick children.
Column 6 indicates the total number of patients admitted to the department over the past day. Information in columns 7-10 is separated from column 6; Column 8 includes only residents of rural areas; columns 9 and 10 indicate admitted patients in accordance with the specified age.
Columns 11 and 12 reflect the movement of patients within the hospital, i.e. patients transferred from one department to another.
Column 13 shows the total number of patients discharged from the department, including patients transferred to other hospitals.
Column 18 indicates the number of people in the department at the beginning of the current day, i.e. on the day of filling out the form. The number of patients shown in column 18 of the previous day should be rewritten in column 5 of the current day.
It is necessary to ensure that the numbers of patients are balanced on a daily basis, i.e. the number of patients shown at the beginning of the current day (gr. 18) was equal to the sum of the numbers of patients who were at the beginning of the previous day (gr. 5), admitted (gr. 6) and transferred (gr. 11) minus the numbers transferred to other departments (gr. 12), discharged (gr. 13) and deceased (gr. 17), i.e. numbers in gr. 5+6+11-12-13-17=column 18.
Separately, column 19 shows information about mothers caring for sick children. In the general movement of sick people, information about married mothers with sick children is not taken into account.
On the back of registration form N 007/u-02, the names and initials of those admitted, transferred within the hospital, discharged, transferred to other 24-hour hospitals, and deceased are indicated. The reverse side data is used to control incoming and outgoing patients and to record the receipt of an inpatient medical card (registration form N 003/u) and a hospital leaving card (registration form N 066/u-02) in the medical statistics office. Thus, complete control over the receipt of medical records of inpatients and records of those leaving the hospital in the medical statistics office is achieved.
Information about the movement of patients in registration form N 007/u-02 (columns 6, 11, 12, 13, 14, 17) must correspond to the list of these patients on the back of the registration form.
When filling out form N 007/у-02, you must remember the following:
- In hospitals where the patient is provided with medical leave (trial or regular), it is necessary to proceed from the following:
- when a patient goes on medical leave, he is not discharged from the hospital; his medical record as an inpatient remains in the department until final discharge.
- during vacation, the patient is removed from meals; for this purpose, the names of all patients on vacation are indicated on the back in registration form N 007/u-02.
- in accounting form N 007/u-02, the departure of a patient on medical leave is not shown in column 13 (patients discharged), and in column 6 (patients admitted) no marks are made when he returns from vacation. Information about patients using medical leave is shown in a separate additional line, while patients who went on vacation for the past day are shown in column 13, those on vacation at the beginning and end of the day are shown in columns 5 and 18, and those returning from vacation - in column 6.
- When transferring a patient from a 24-hour hospital to a day hospital and vice versa, consider the patient as discharged and newly admitted.
The completed sheets of accounting form N 007/у-02 are transferred every day to the medical statistics office or to another employee responsible for keeping records of patients, who daily compiles data for the hospital as a whole and records them in the consolidated accounting form N 007\у-02.
Note:
For day hospital patients, the day of admission and the day of discharge are counted as 2 days of treatment:
For patients in a 24-hour hospital, the day of admission and the day of discharge are counted as 1 bed day.
Appendix No. 3. Instructions for filling out registration form No. 016/u-02 “Summary statement of the movement of patients and beds by hospital, department and bed profile of a 24-hour hospital, day hospital at a hospital institution”
Appendix No. 3
________________
Registration form N 016/u-02 “Summary statement of the movement of patients and beds by hospital, department and profile of beds in a round-the-clock hospital, day hospital at a hospital institution” (hereinafter referred to as the Summary statement) is compiled monthly for each department and for the hospital as a whole. At the end of the month, information on departments or on the profile of beds, as well as on the hospital as a whole, shown in form N 007/у-02, is summarized and transferred to form N 016/у-02. Table No. 1 (appendix) shows the procedure for transferring information from f. N 007/у-02 to the Summary Statement.
The summary sheet makes it possible to monitor correct use bed capacity, the deployment of beds in departments and in the hospital as a whole (by month, quarter, half year). The data from the summary statement characterize the capacity of the hospital, its structure and make it possible to calculate such indicators as: use of bed capacity, average duration patient stay in hospital, average bed occupancy, bed turnover, mortality (both by department and in the hospital as a whole).
Column 4 of the Summary Statement shows the average monthly number of beds by month, and “per year” - the average annual number of beds. To determine the average monthly number of beds, the data in column 3 of accounting form N 007/u-02 is calculated for the month and the resulting amount is divided by the number calendar days month. To determine the number of average annual beds, the entries in column 4 of accounting form N 016/у-02 are added up and the resulting amount is divided by 12.
The number of bed days spent by patients (column 18 of the Consolidated Statement) is obtained by summing the number of patients, consisting of 9 in the morning every day for all days of the month (column 18 of accounting form N 007/u-02). The number of patients includes patients in temporary and temporary beds (added).
The number of bed days closed for repairs and other reasons (column 19 of accounting form N 01.6/y-02) is obtained by summing the numbers in column 4 in accounting form N 007/y-02.
The number of bed days for care (column 20 of accounting form N 016/у-02) is obtained by summing the numbers in column 19 in accounting form N 007/у-02.
In hospitals where the patient is provided with medical leave, in the summary statement of accounting form N 016/u-02, column 18 shows the total number of bed days spent by patients in the hospital, and an additional line in column 18 shows the total number of days spent by patients on vacation for all days of the month (from form N 007/у-02). The days that patients are on medical leave should not be excluded from the total number of bed days when calculating such indicators as the average bed occupancy, the average length of stay of a patient in a bed, and bed turnover.
After filling out the summary statement for the month (for the year), it is necessary to check the movement of patients in the department and in the hospital as a whole. To do this, take the number of patients at the beginning of the reporting period (month, year) - column 5 - add the number of admitted patients (column 6) and transferred patients within the hospital (column 10), minus the number of those transferred to other departments (column 11), discharged (column 12), deceased (column 16) i.e. columns 5+6+10-11-12-16= column 17.
The data from the summary statement (accounting form N 016/u-02) is used to fill out table N 1 “Bed fund and its use” of section III “Hospital activities” of form N 30 “Information about the medical institution”.
Application
Table No. 1. The procedure for transferring information from the daily sheet (form N 007/u-02) to the summary sheet (form N 016/u-02)
Table No. 1
Graphs of form N 016/у-02 | Graphs of form N 007/у-02 |
||
Name | Name |
||
Total actually deployed beds | Actually deployed beds, including beds rolled up for repairs |
||
Including beds closed for repairs |
|||
Number of patients at the beginning of the reporting period | Number of patients at the beginning of the past day |
||
Total number of patients admitted | Total number of patients admitted (without those transferred within the hospital) |
||
Patients were admitted from day hospitals | Patients were admitted, including from the day hospital (from group 6) |
||
Sick villagers received | Received sick (without those transferred within the hospital) rural residents (from group 6) |
||
Patients aged 0-17 years were admitted | Patients were admitted (without those transferred within the hospital) aged 0-17 years (from group 6) |
||
Patients aged 60 years and older were admitted | Patients were admitted (without those transferred within the hospital) aged 60 years and older (from group 6) |
||
Patients transferred from other departments |
|||
Patients were transferred to other departments |
|||
Total number of patients discharged | Total number of patients discharged |
||
Patients discharged to day hospital | Patients were discharged to the day hospital (from group 3) |
||
Patients were discharged to a 24-hour hospital | Patients were discharged from a day hospital to a 24-hour hospital |
||
Patients discharged after transfer to other hospitals |
|||
Died | |||
Number of patients at the end of the reporting period | Number of patients at the beginning of the current day - total |
||
Number of bed-days spent by patients (days of treatment) | Consists of patients at the beginning of the current day - total (total for month, year) |
||
Number of bed days closed | Including beds closed for repairs (total for month, year) |
||
Care bed days spent | Consists of mothers with sick children (total for month, year) |
||
Appendix No. 4. Instructions for filling out registration form No. 007ds/u-02 “Sheet for daily registration of the movement of patients and the bed capacity of a day hospital at an outpatient clinic, hospital at home”
Appendix No. 4
Form N 007дс/у-02 "Sheet of daily registration of the movement of patients and bed capacity of a day hospital at an outpatient clinic, hospital at home" is filled out by health care institutions that have organized day hospitals or hospitals at home in accordance with the current order of the Ministry of Health Russian Federation"On the organization of activities of day hospitals in medical institutions."
Form N 007ds/u-02 is filled out daily by a nurse after the end of the shift for the past day (shift) and at the beginning of the current day as a whole for the day hospital, if it has one profile of beds, or separately for each profile, if the hospital has several beds profiles.
Note. If the day hospital operates in 2 shifts, then column 3 “Number of beds” shows the number actually deployed (in accordance with the order of the institution), and column 4 “Average monthly” shows the beds taking into account the shifts of work, i.e. based on the calculation that 1 place is equivalent to 2 (3) places depending on the number of shifts.
Columns 5-13 show information about the movement of patients over the past 24 hours from 9 a.m. of the previous day to 9 a.m. of the current day.
Column 5. “The number of patients at the end of the past day.” The number of patients from column 14 “Consists of patients at the beginning of the current day”, shown on the sheet for the previous day, is rewritten, i.e. the number of patients in group 14 for the previous day is equal to the number of patients in group 5 for the current day.
Column 6. “Patients admitted - Total” - shows the number of patients admitted. Surnames I.O. received is indicated on the back of the form.
Column 7. “Including from 24-hour hospitals.” Of the total number of admitted patients (from column 6), the number of patients admitted from a 24-hour hospital is shown (Last name, first name, first name of those admitted is indicated on the reverse side of the form).
Column 8. "Rural residents". Of the total number of admitted patients (from column 6), the number of patients living in rural areas is shown.
Column 9. "0 - 17". Of the total number of admitted patients (from column 6), the number of patients aged 0 to 17 years inclusive is shown.
Column 10. "60 and older." Of the total number of admitted patients (from column 6), the number of patients aged 60 years and older is shown.
Column 11. “Patients discharged - Total.” Shows the number of patients discharged from the day hospital. Last name, I., O. written out is indicated on the back of the form.
Column 12. “Discharged to 24-hour hospitals.” The number of patients (from group 1) discharged from a day hospital to a 24-hour hospital (either the same institution or another) is shown.
Note. When a patient is admitted from a 24-hour hospital to a day hospital and vice versa, consider the patient as discharged and newly admitted.
Column 13. “Died.” The number of patients who have died is shown.
Column 14. "At the beginning of the current day, the number of patients is - Total." The number of patients registered at 9 a.m. of the current day is shown. It is necessary to ensure that the numbers are balanced daily. So, the number of patients in column 14 is equal to: column 5 (patients included) plus column 6 (patients admitted) minus column 11 (patients discharged) minus column 13 (died). Balance: gr.5 + gr.6 - gr.11 - gr.13 = gr.14.
Column 15. “Including rural residents.” The number of patients (from group 14) living in rural areas is indicated.
Form N 007-ds/u-02 can be used as a summary form (analogous to form N 016/u-02). In this case, column No. 1 indicates the months (from January to December) and the final line “total for the year.”
Column 5 shows “the number of patients at the beginning of the reporting period,” and column 16 shows “the number of patients at the end of the reporting period.”
Column 17 shows the number of days of treatment (for the corresponding period).
Column 18 shows the number of days of treatment spent by rural residents (from column 17."
Note:
- The day of admission and the day of discharge from the day hospital are counted as 2 days of treatment.
- All days of treatment are taken into account, including weekends from the patient’s admission to the day hospital until his discharge.
- For a patient in a day hospital of any type, a “Medical record of an inpatient patient” (registration form N 003/u) is created when transferring him from a 24-hour hospital to a day hospital of the same institution and vice versa, it is allowed to maintain one medical history, in this case its number is indicated through a fraction: in the numerator - the medical history number of a 24-hour hospital, in the denominator - daytime.
- When a patient is discharged and admitted to a 24-hour or day hospital of the same institution, two “Statistical cards of those leaving the hospital...” (form N 066/u-02) are filled out for the patient.
Appendix No. 5. Instructions for filling out registration form No. 066/u-02 “Statistical card of a person leaving a 24-hour hospital stay, a day hospital at a hospital institution, a day hospital at an outpatient clinic...
Appendix No. 5
INSTRUCTIONS
on filling out registration form N 066/у-02 "Statistical card of a retired
from a 24-hour hospital, a day hospital with
hospital facility, day hospital at
outpatient clinic, hospital at home"
________________
*Probably an error in the original. It should read: "dated 12/30/2002". - Note "CODE".
“Statistical card of a person leaving a hospital for round-the-clock stay, a day hospital at a hospital institution, a day hospital at an outpatient clinic, a hospital at home” (hereinafter referred to as the Card of a person leaving a hospital) is a statistical accounting document containing information about a patient who left a hospital (day hospital) . To be filled out for all those leaving the hospital (day hospital) of any type, including postpartum women. It is also filled out for retired newborns who were born sick or became ill in a hospital.
The number of the Leaver's Card and points from 1 to 21 are filled in upon admission of the patient (mother) to the hospital emergency room, maternity hospital or day hospital. The doctor of the admission department of the hospital (maternity hospital) or the doctor of the day hospital monitors the correct and timely completion of the above-mentioned points of the Leaver Card.
Points 22 - 25.1, 28 - 29 and 31 are completed by the attending physician upon discharge of the patient.
Lines of paragraphs 26 and 27 are filled in by doctors of the relevant departments.
Sections of paragraph 29 “Hospital pathological diagnosis” and paragraph 30 “Main cause of death” are filled out in the pathological department.
The heads of the department are responsible for monitoring the correct completion of the items on the Retiree Card.
The doctor of the medical statistics office (or the person entrusted with the function of monitoring the coding of diagnoses and operations) monitors the correctness of coding of diagnoses (if necessary, codes diagnoses), operations, and complications of operations.
Coding of diagnoses of the hospital (day hospital) and the referring institution is carried out according to the “International Statistical Classification of Diseases and Related Health Problems”, tenth revision (ICD-10).
If the hospital (day hospital) has electronic computer equipment and the corresponding software product. The leaver's card can be filled out automatically at the admission department level.
Subsequent automated processing of the Retiree Card allows you to:
- formation and updating of the register of the attached population;
- collection and generation of statistical information on each case of hospitalization provided medical services, temporary disability, operations performed;
- accounting and maintenance medical policies compulsory and voluntary insurance;
- payment system for medical care provided;
- examination of the quality of care provided (compliance with treatment duration standards, drug treatment, analysis of the discrepancy between diagnoses of emergency medical care - hospital, clinic - hospital, etc.);
- personalized accounting of the consumption and cost of medicines.
The procedure for filling out the Retiree Card:
In the title of the Leaver's Card, the corresponding type of hospital is emphasized and the number of the inpatient's medical card is recorded (form N 003/u).
Item 1. Patient code. The patient identification number or other code accepted at the health care facility is indicated.
Clause 2. Full name Last name, first name, patronymic are written down without abbreviations based on an identity document. In the absence of a document, based on the patient’s oral statement, and in the absence of contact with the patient, “unidentified” is entered. When filling out the Discharged Card for a newborn (born sick or sick in a hospital), the mother’s last name, first name, and patronymic are entered.
Clause 3. Gender. The patient's gender is indicated by a dash or circle in the appropriate position: men - 1, women - 2.
Item 4. Date of birth. The patient's date of birth is indicated in the format: day, month, year (year of birth - in full).
For example, the date of birth entry "May 5, 2001" should look like 05/05/2001.
Clause 5. Identity document. The data of the patient’s identity document is recorded (for children - birth certificate, parent’s document, guardian’s document); if there is no document, the item is not filled in, a dash is entered.
Clause 6. Address: registration at place of residence. The address of the place of residence according to the passport data is indicated: state, subject of the Russian Federation, locality (city, village, village, etc.), administrative District, street, house, building, apartment.
Clause 7. Code of the territory of residence. Filled out according to the code of the subject of the Russian Federation according to the current classifier.
Inhabitant. The attribute “city resident”, “village resident” is marked by circling the corresponding position (in accordance with the administrative division).
Clause 8. Insurance policy. If the type of payment is medical insurance, then the details of the insurance policy and the insurer (insurance company, territorial Compulsory Medical Insurance Fund, branch of the Federal Compulsory Medical Insurance Fund) are recorded with the obligatory indication of the code of the territory in which the insurer is located, according to the current classifier.
Clause 9. Type of payment: Compulsory medical insurance - 1, budget - 2, paid services - 3, incl. VHI - 4, other - 5; the corresponding attribute is underlined or circled.
Point 10. Social status. Positions 2-6 (“preschooler: organized,” “preschooler: disorganized,” “student,” “working,” “not working”) refer to the patient’s employment. Marked by circling the corresponding position. The “code” position is filled in for military personnel according to the current classifier.
Clause 11. Category of benefits. Filled out for patients belonging to the category of the population entitled to preferential provision of medicines and medical products; the corresponding position is noted. If the patient has a benefit category that is not indicated in the Statcard, then the “other” position is noted.
Clause 12. Directed by. The name of the institution (day hospital) that referred the patient is entered; if there is a referral, the number and date of issue of the referral are indicated.
Clause 13. Delivered by. The hospitalization channel is recorded (for example, " ambulance", "self-referral", etc.), hospitalization channel code according to the classifier operating in the territory, ambulance squad number.
Item 14. Diagnosis of the referring institution. The name and ICD-10 code of the diagnosis of the referring institution are entered.
Point 15. Diagnosis of the emergency department. The name and ICD-10 code of the diagnosis of the emergency department are entered.
Point 16. Delivered in a state of intoxication. Marked with a prime in the corresponding position when the condition is present alcohol intoxication or state of intoxication recorded in the patient’s MC and/or protocol medical examination(in accordance with the order of the USSR Ministry of Health dated 09/08/88 N 694 “On measures to further improve medical examination to establish the fact of alcohol consumption and intoxication” and the Interim Instruction of the USSR Ministry of Health “On the procedure for medical examination to establish the fact of alcohol consumption and intoxication” dated 01.09.88 N 06-14/33-14.
Item 17. Hospitalized for this disease this year. The corresponding position is noted: “primarily”, “repeatedly” - based on the patient’s oral statement about initial or repeated admission to this medical institution By this disease, "By emergency indications"- based on the decision of the emergency department doctor or as planned.
Point 18. Delivered to the hospital from the onset of the disease (injury). The time elapsed from the onset of the disease (injury) is noted based on the decision of the emergency department doctor or according to the patient.
Clause 19. Trauma. Filled out if the patient has an injury: the corresponding position is noted based on the oral statement of the patient or the referring institution, or the conclusion of the ambulance.
Clause 20. Date and time of receipt emergency department. The date and time of the patient's admission to the hospital emergency department are recorded.
Clause 21. Name of department, date and time of admission. The name of the department where the patient is hospitalized, date and time are indicated (filled in in the department where the patient was admitted).
Signature of the emergency department doctor responsible for the patient’s hospitalization, or the day hospital doctor, the doctor’s personal code.
Item 22. Date and time of discharge (death). The date and time of end of hospitalization are recorded.
(In case of death, the “Time” field must be filled in).
Item 23. Duration of hospitalization. The number of bed days spent in a hospital or day hospital is recorded (in a 24-hour hospital, the day of admission and the day of discharge is counted as one bed day, in a day hospital - as two days of treatment).
Item 24. Outcome of hospitalization. The outcome of hospitalization is noted in the appropriate position. If the patient is discharged to a 24-hour day hospital, then two positions are marked: “1” - discharged, “2” - incl. to a day hospital (or “3” - to a 24-hour hospital).
Clause 24.1. Result of hospitalization. Marked in the appropriate position.
Clause 25. Certificate of incapacity for work. The dates of opening and closing of a sick leave certificate or certificate of temporary incapacity for work are recorded (in the Leaver's Card, make an entry ""certificate" if a certificate of temporary incapacity for work is registered). If the document of temporary incapacity for work is not closed in a hospital, then in paragraph 25 only the date of opening and this position is not being developed for the generation of reporting form N 16-in “Information on temporary disability”.
Clause 25.1. Patient care. To be filled in if sick leave issued for patient care. The age and gender of the person caring for the patient is indicated.
Point 26. Patient movement across departments (bed profiles). The patient's movement through departments and bed profiles are recorded, indicating the date of admission (departure); diagnosis code according to ICD-10; attending physician code; type of payment. Codes medical standards, signs of completion or interruption of hospitalization are indicated according to current classifiers.
Note: codes of medical standards and signs of completion or interruption of hospitalization are not indicated if:
- there is no medical standard classifier in the hospital;
- this information is not included in the development when using the information system.
Point 27. Surgical operations. To be completed during surgery. Recorded: date; hour; surgeon code, department code; name and code of the operation: anesthesia code; name and codes postoperative complications; use of special equipment. Codes of operations and their complications are indicated according to the current classifier.
If there are several operations, the “main operation” must be marked with a stroke. In the appropriate columns, enter the code of the department (column 3) to which the operation belongs (i.e., the department in which the surgeon who performed this operation is registered), indicate the personal codes of the surgeons (column 2) and the type of payment (column 13) .
Point 28. Examination for syphilis and HIV infection. To be completed if there is an examination for syphilis or HIV infection: noted in the appropriate position.
Point 29. Hospital diagnosis (at discharge). The final diagnosis of the disease is recorded in the following sequence: “Main, complication of the main, concomitant diseases” and the corresponding ICD-10 codes. In the event of the patient's death and an autopsy examination, the pathological diagnosis is recorded in a sequential order: "main, complication, concomitant." If there is a bicasual or multicasual diagnosis, one nosological unit is coded in the “main” heading, which is used for statistical development.
Item 30. Main cause of death. The name and ICD-10 code of the main (initial) cause of death are indicated.
Item 31. Defects of the prehospital stage. Defects at the prehospital stage are noted by underlining in the appropriate position based on the decision of the attending physician, head of the department, or expert doctor.
Note: Uniform Coding Rules clinical diagnoses and causes of death in statistical documents are set out in Methodical manual Research Institute of Social Hygiene, Economics and Health Management named after N.A. Semashko RAMS "Use of the international statistical classification of diseases and health-related problems, tenth revision in the practice of domestic medicine."
font size
ORDER of the Ministry of Health of the Russian Federation dated November 13, 2003 545 ON APPROVAL OF INSTRUCTIONS FOR COMPLETING MEDICAL RECORDING DOCUMENTATION (2019) Relevant in 2018
INSTRUCTIONS FOR COMPLETING RECORDING FORM N 066/U-02 "STATISTICAL CARD OF A DEPARTURE FROM A 24-HOUR STAY HOSPITAL, A DAY HOSPITAL AT A HOSPITAL INSTITUTION, A DAY HOSPITAL AT AN OUTPATIENT POLYCLINIC INSTITUTION AI, HOSPITAL AT HOME" (APPROVED BY ORDER OF THE MINISTRY OF HEALTH OF THE RUSSIA DATED DECEMBER 30, 2002 N 413)
“Statistical card of a person leaving a hospital for round-the-clock stay, day hospital at a hospital institution, day hospital at an outpatient clinic, hospital at home” (hereinafter referred to as the Card of Departure) is a statistical accounting document containing information about a patient who left a hospital (day hospital). To be filled out for all those leaving the hospital (day hospital) of any type, including postpartum women. It is also filled out for retired newborns who were born sick or became ill in a hospital.
Item 1. Patient code. The patient identification number or other code accepted at the health care facility is indicated.
Clause 2. Full name Last name, first name, patronymic are written down without abbreviations based on an identity document. In the absence of a document, based on the patient’s oral statement, and in the absence of contact with the patient, “unidentified” is entered. When filling out the Discharged Card for a newborn (born sick or sick in a hospital), the mother’s last name, first name, and patronymic are entered.
Clause 3. Gender. The patient's gender is indicated by a dash or circle in the appropriate position: men - 1, women - 2.
Item 4. Date of birth. The patient's date of birth is indicated in the following format: day, month, year (year of birth - in full).
Clause 5. Identity document. The data of the patient’s identity document is recorded (for children - birth certificate, parent’s document, guardian’s document); if there is no document, the item is not filled in, a dash is entered.
Clause 6. Address: registration at place of residence. The address of the place of residence according to the passport data is indicated: state, subject of the Russian Federation, locality (city, village, village, etc.), administrative district, street, house, building, apartment.
Clause 7. Code of the territory of residence. Filled out according to the code of the subject of the Russian Federation, according to the current classifier.
Inhabitant. The attribute “city resident”, “village resident” is marked by circling the corresponding position (in accordance with the administrative division).
Clause 8. Insurance policy. If the type of payment is medical insurance, then the details of the insurance policy and the insurer (insurance company, territorial Compulsory Medical Insurance Fund, branch of the Federal Compulsory Medical Insurance Fund) are recorded with the obligatory indication of the code of the territory in which the insurer is located, according to the current classifier.
Clause 9. Type of payment: compulsory medical insurance - 1, budget - 2, paid services -3, incl. VHI - 4, other - 5; the corresponding attribute is underlined or circled.
Point 10. Social status. Positions 2-6 (“preschooler: organized,” “preschooler: disorganized,” “student,” “working,” “not working”) refer to the patient’s employment. Marked by circling the corresponding position. The “code” position is filled in for military personnel according to the current classifier.
Clause 11. Category of benefits. Filled out for patients belonging to the category of the population entitled to preferential provision of medicines and medical products, the corresponding position is noted. If the patient has a benefit category. not indicated in the Statcard, then the position “other” is marked.
Clause 12. Directed by. The name of the institution (day hospital) that referred the patient is entered; if there is a referral, the number and date of issue of the referral are indicated.
Clause 13. Delivered by. The channel of hospitalization is recorded (for example, “ambulance”, “self-referral”, etc.), the code of the hospitalization channel according to the classifier operating in the territory, the number of the ambulance squad.
Item 14. Diagnosis of the referring institution. The name and ICD-10 code of the diagnosis of the referring institution are entered.
Point 15. Diagnosis of the emergency department. The name and ICD-10 code of the diagnosis of the emergency department are entered.
Point 16. Delivered in a state of intoxication. It is marked with a stroke in the appropriate position in the presence of a state of alcoholic intoxication or a state of stupefaction, recorded in the MK of an inpatient patient and/or the medical examination protocol (in accordance with the order of the Ministry of Health of the USSR dated 09/08/88 N 694 “On measures to further improve medical examination to establish fact of alcohol consumption and state of intoxication" and the Temporary Instruction of the USSR Ministry of Health "On the procedure for medical examination to establish the fact of alcohol consumption and state of intoxication" dated 01.09.88 N 06-14/33-14.
Item 17. Hospitalized for this disease this year. The corresponding position is noted: “primarily”, “repeatedly” - based on the patient’s oral statement about initial or repeated admission to a given medical institution for a given disease, “for emergency indications” - based on the decision of the doctor in the admission department, or on a planned basis.
Point 18. Delivered to the hospital from the onset of the disease (injury). The time elapsed from the onset of the disease (injury) is noted based on the decision of the emergency department doctor, or according to the patient.
Clause 19. Trauma. Filled out if the patient has an injury: the corresponding position is noted based on the oral statement of the patient or the referring institution, or the conclusion of the ambulance.
Clause 20. Date and time of admission to the emergency department. The date and time of the patient's admission to the hospital emergency department is recorded.
Clause 21. Name of department, date and time of admission. The name of the department where the patient is hospitalized, the date and time are indicated (to be completed in the department where the patient was admitted).
Signature of the emergency department doctor responsible for the patient’s hospitalization, or the day hospital doctor, the doctor’s personal code.
Item 22. Date and time of discharge (death). The date and time of end of hospitalization is recorded.
(In case of death, the “Time” field must be filled in).
Item 23. Duration of hospitalization. The number of bed days spent in a hospital or day hospital is recorded (in a 24-hour hospital, the day of admission and the day of discharge is counted as one bed day, in a day hospital - as two days of treatment).
Item 24. Outcome of hospitalization. The outcome of hospitalization is noted in the appropriate position. If the patient is discharged to a 24-hour day hospital, then two positions are marked: “1” - discharged, “2” - incl. to a day hospital (or “3” - to a 24-hour hospital).
Clause 24.1. Result of hospitalization. Marked in the appropriate position.
Clause 25. Certificate of incapacity for work. The dates of opening and closing of a sick leave certificate or a certificate of temporary disability are recorded (in the Leaver's Card, make an entry “certificate” if a certificate of temporary disability is registered). If the temporary disability document is not closed in the hospital, then in clause 25 only the date of opening is filled in and this position is not used for development for the generation of reporting form N 16-in “Information on temporary disability”.
Clause 25.1. Patient care. To be completed if sick leave was issued to care for a patient. The age and gender of the person caring for the patient is indicated.
Point 26. Patient movement across departments (bed profiles). The patient’s movement across departments and bed profiles are recorded, indicating the date of admission (departure); diagnosis code according to ICD-10; attending physician code; type of payment. Codes of medical standards, signs of completion or interruption of hospitalization are indicated according to current classifiers.
Note: codes of medical standards and signs of completion or interruption of hospitalization are not indicated if:
There is no medical standard classifier in the hospital;
This information is not included in the development when using the information system.
Clause 27. Surgical operations. To be completed during surgery. Recorded: date; hour; surgeon code, department code; name and code of operation; anesthesia code; name and codes of postoperative complications; use of special equipment. Codes of operations and their complications are indicated according to the current classifier.
If there are several operations, the “main operation” must be marked with a stroke. In the appropriate columns, enter the code of the department (column 3) to which the operation belongs (i.e., the department in which the surgeon who performed this operation is registered), indicate the personal codes of the surgeons (column 2) and the type of payment (column 13) .
Point 28. Examination for syphilis and HIV infection. To be completed if there is an examination for syphilis or HIV infection: noted in the appropriate position.
Point 29. Hospital diagnosis (at discharge). The final diagnosis of the disease is recorded in the following sequence: “Main, complication of the main, concomitant diseases,” and the corresponding ICD-10 codes. In the event of the patient's death and an autopsy examination is performed, the pathological diagnosis is recorded in the following order: "main, complication, concomitant." If there is a bicasual or multicasual diagnosis, one nosoological unit is coded in the “main” heading, which goes into statistical development.
Item 30. Main cause of death. The name and ICD-10 code of the main (initial) cause of death are indicated.
Item 31. Defects of the prehospital stage. Defects at the prehospital stage are noted by underlining in the appropriate position based on the decision of the attending physician, head of department, or expert doctor.
Note: Unified rules for coding clinical diagnoses and causes of death in statistical documents are set out in the Methodological Manual of the Research Institute of Social Hygiene, Economics and Health Management named after. N.A. Semashko RAMS "Use of the international statistical classification of diseases and health-related problems, tenth revision in the practice of domestic medicine."
Loading...