22.09.2017			12 – 20 – 403		Heads of medical organizations To the directors of the branches of the “TFOMS of the Volgograd Region” Heads of CMO
On the application of tariffs when providing medical care in outpatient setting

The state institution “Territorial Compulsory Medical Insurance Fund of the Volgograd Region” explains following a video conference meeting on the organization and payment of medical care in an outpatient setting.

Based on the Tariff Agreement in the field of compulsory health insurance of the Volgograd region for 2017, per unit of payment for medical care, including emergency care provided on an outpatient basis, the following are accepted:

Medical visits (for preventive purposes, for other purposes, when providing emergency medical care),

Visits to a paramedic (midwife) conducting an independent appointment (for preventive purposes, for other purposes, when providing emergency medical care),

Treatment (completed case, including during medical rehabilitation, during dispensary observation),

A completed case of medical examination of certain groups of the adult population,

Completed case of preventive medical examinations adult population,

Completed case of medical examination of those staying in inpatient institutions orphans and children in difficult life situations,

A completed case of medical examination of orphans and children left without parental care, including those adopted, taken under guardianship (trusteeship) in a foster or foster family,

Completed case of medical examinations of minors,

Visits to the health center,

Treatment and diagnostic services ( CT scan, magnetic resonance imaging, laboratory diagnostic),

Per capita funding standard.

A visit is a patient’s contact with a doctor (except for doctors of paraclinical specialties), paramedical personnel conducting independent appointments, in an outpatient clinic organization (unit), as well as at home, including a set of necessary preventive, therapeutic and diagnostic services, with subsequent registration in medical record of an outpatient (diagnosis, prescription of examination, treatment, records of dynamic observation and other records based on observation of the patient).

TO visits for preventive and other purposesshould include:

Visits regarding examinations upon admission to study, in preschool institutions, when sending children to summer health camps, sanatoriums, boarding houses and other children's health organizations; inspections of contingents subject to periodic inspections; examinations of the population during medical examination, examinations when deciding whether to carry out preventive vaccinations;

Visits to pregnant women normal pregnancy, visiting women who applied for contraceptive use, etc.;

Patronage visits to healthy children in the first year of life;

Visits to health centers;

Visits in connection with obtaining certificates and other medical documents;

One-time visits regarding illness (injury, other condition);

Visits in connection with registration health resort card, registration of directions to medical and social examination;

Consultations regarding illness (injury, other condition);

If, during a preventive examination, the doctor only suspected a disease, but did not make a diagnosis, and referred the patient to an appropriate specialist to establish a diagnosis, this visit to the doctor who conducted the examination should be taken into account as made for preventive purposes.

As part of each visit, carried out at the expense of compulsory health insurance, medical organizations in mandatory keep records directions

An appeal regarding a disease is a completed case of treatment of a disease (injury or other condition) by a doctor of one specialty, a paramedic (midwife) with a frequency of at least two visits for one disease.

Appeal for the purpose of medical rehabilitation in an outpatient setting is a complete case of medical rehabilitation from doctors of several specialties and a set of treatment and diagnostic procedures in accordance with regulatory documents regulating the provision of medical rehabilitation.

An appeal as a complete case consists of initial and repeat visits regarding the disease, treatment, diagnostic and rehabilitation measures, which result in recovery, improvement, referral of the patient to a day hospital, for hospitalization in a 24-hour hospital, for a medical and social examination, etc. P.

To appeals should also include the totality of visits regarding the pathology of pregnancy, visits regarding anomalies of refraction and accommodation (except for visits regarding presbyopia of persons aged 40 years and older), anomalies of speech, voice and hearing, etc.

To appeals should also include carrying outdispensary observation as part of the provision of primary health care to patients with chronic non-communicable diseases and patients with high risk their development, includingvisits within a month.

At the same time, cases of treatment (treatment with therapeutic purpose) one patient by different specialists (for example: a therapist and a physiotherapist; a paramedic and a traumatologist; a cardiologist and an ophthalmologist, etc.). When treating one pathology by doctors of different specialties, one of the specialists acts as the attending physician and bills the treatment for treatment purposes, while other specialists act as consultants and bills one-time visits for the disease.

As part of each application regarding a disease (injury, other condition), carried out at the expense of compulsory health insurance, medical organizations are required to keep records of directly performed visits as well as directions for laboratory testing in a centralized laboratory.

A visit for an urgent purpose in an outpatient setting - provision of primary pre-hospital, primary medical, primary specialized health care (including in a clinic, hospital emergency department, at home when calling a medical professional) in case of sudden acute diseases and conditions (including injuries, poisoning), exacerbation of chronic diseases that are not life-threatening for the patient.

As a pre-hospital health care emergency health care can be provided by paramedics (paramedics, midwives) who have the right to independently receive patients (determined by order of the chief physician of the medical organization).

Medical assistance to patients who contact a medical organization with signs of an emergency condition is provided immediately. Emergency medical care at home is provided no later than 2 hours after the patient or other person receives a request for emergency care at home.

A mandatory condition for classifying a visit as an emergency visit in an outpatient clinic (unit) or at home is the provision of emergency treatment and diagnostic services on a free basis (at the expense of the medical organization providing medical care) medicines, medical products And dressing material, necessary for the provision of emergency medical care in accordance with the list of vital and essential medicines and medical products necessary for the provision of primary health care in an outpatient setting in an emergency form within the framework of the Territorial Compulsory Medical Insurance Program.

When a patient comes to the emergency department of a hospitalfor emergencies and urgent indications (by ambulance, self-referral, etc.) without subsequent hospitalization in this hospital in the case of therapeutic and diagnostic measures (including consultation and examination by a doctor emergency indications with the aim of differential diagnosis disease or condition) this visit is considered visiting in an emergencyand is presented for payment according to a group of medical service codes 2.82.* "Doctor appointments in reception department hospital." In the case of the use of drugs, medical devices and dressings, the primary medical documentation must contain a record of their use; when performing diagnostic procedures (for example: electrocardiography, radiography, examination of biomaterial, etc.) - the result of the study; when conducting emergency consultations indications – a complete detailed record of the examination and a specialist’s conclusion. In the case of examinations by doctors of different specialties for the purpose of differential diagnosis in the emergency room, each examination is billed as a separate visit for urgent purposes to a doctor of the corresponding specialty. In this case, each of the specialists makes a complete detailed record of the examination and a conclusion in the medical documentation. When a tomographic examination (computed tomography, magnetic resonance imaging) is carried out in a medical organization, when a patient visits the emergency department for emergency and emergency indications, a separate service is billed according to one of the codes:

2.82.26 “Doctor’s appointment in the emergency department of a hospital with a CT scan without contrast”

2.82.27 “Medical appointment in the emergency department of a hospital with a contrast-enhanced CT scan”

2.82.28 “Doctor’s appointment in the emergency department of a hospital with MRI without contrast”

2.82.29 “Medical appointment in the emergency department of a hospital with contrast-enhanced MRI”

according to the profile of the specialist who prescribed this study., with justification in the medical documentation for its implementation. The tariff for these codes includes the cost of a medical appointment and the relevant research. The remaining specialists (if necessary) submit their examinations invoiced using the usual codes for visits to the emergency department without conducting a corresponding study (code group 2.82.*, with the exception of the above).

We draw your attention to the fact that cases of examination of patients in the emergency department by a specialist doctor for the purpose of selecting them for subsequent planned hospitalization are not included in invoices.

Medical organizations keep separate records of visits for preventive purposes (visits to a health center in connection with medical examination of certain population groups, clinical observation, preventive examination, consultations, etc.), emergency medical care and visits for diseases.

Visits made during the day by a patient to the same doctor (paramedical worker) are counted as one visit.

Tariffs for requests from a physiotherapist, a medical doctor physical therapy, reflexology includes the costs of physiotherapy, reflexology procedures, massage, etc.

Doctor consultations (consultative medical appointments)By medical specialties are used by medical organizations that have advisory (consultative and diagnostic) units and are counted as visits for preventive purposes. A mandatory condition for submitting a case for payment consultation according to tariffs of code group 2.81.* is the presence of a referral for consultation.

Execution casescomputed and magnetic resonance imaging performed on outpatients(including those insured outside the Volgograd region) are taken into account separately from outpatient visits and are billed for separate services.

Payment for outpatient medical care provided to insured persons at the place of attachment is carried out by insurance medical organizations for a completed visit, treatment or service, the cost of which includes an appointment with a specialist, medical manipulation and examinations prescribed by him. Payment for diagnostic studies (except for computed and magnetic resonance imaging, centralized services diagnostic laboratories(clinical diagnostic, cytological, prenatal screening, prenatal diagnostics)), carried out in the direction of a medical organization to other medical organizations, is carried out in the form of mutual settlements between them without issuing invoices to insurance medical organizations.

Payment for primary health care provided by local therapists, local pediatricians, doctors general practice to the population not attached to this medical organization, is carried out by insurance medical organizations only when providing medical care for emergency conditions according to tariffs for completed emergency visits. If necessary, repeat visits are made to non-precinct general practitioners and pediatricians and are paid at the rates for a one-time visit for a disease. Visits made to the population not attached to a given medical organization for the purpose of carrying out preventive vaccinations within the framework of the national calendar of preventive vaccinations and the calendar of preventive vaccinations for epidemic indications, for the purpose of dynamic monitoring of the state of development of the child, are paid by insurance medical organizations at the rates for a visit performed for preventive purposes to a doctor. - general practitioner and non-precinct pediatrician. Medical examinations for the population not affiliated with this medical organization are not subject to payment.

Visit to nursing staff

Visits by paramedical personnel (paramedics, midwives) are subject to accounting and are presented for payment in cases of self-administration in medical outpatient clinics, medical and paramedical health centers, first aid posts, including visits regarding procedures (with a recording of the examination in the medical documentation). Midwives of a medical outpatient clinic, a local hospital, a feldsher-midwife station, who independently receive (when assigned to them certain functions of the attending physician, assigned by order of the institution) pregnant women, postpartum women, gynecological patients, children of the first year of life, can enter codes of the corresponding services in the account register for payment. Patients visiting the same health care provider during the day are counted as one visit.

Certain features of billing for cases of provision of primary specialized medical care in an outpatient setting

The formation of registers of information and invoices for medical care provided to an insured person during the process of allergen-specific immunotherapy (hereinafter referred to as ASIT) by an allergist-immunologist should be carried out in accordance with the following steps:

1. When you first contact an allergist-immunologist for diagnosis and treatment preliminary examination to identify indications for ASIT (examination by a doctor, laboratory examination and diagnostic procedures - skin tests, prescription of a treatment regimen) when creating registers of information and invoices, the medical service code is used:2.78.7 – Contact an allergist-immunologist for therapeutic purposes.It is permissible to bill at the initial stages of “titration” the dose of allergodrug treatment for therapeutic purposes for several visits to administer the drug of one concentration, until reaching a constant concentration of the drug for long-term ASIT.

2. When directly conducting ASIT according to the scheme prescribed by the allergist-immunologist, when creating registers of information and bills, the medical service code is used:2.88.9 – One-time visit to an allergist-immunologist regarding a disease.

If, during the procedure for introducing the allergen(s) according to the prescribed scheme, complications or exacerbations arose and medical care was required directly from a doctor using medications, then when creating registers of information and invoices, the medical service code is used:2.80.15 – Emergency visit to an allergist-immunologist.

The formation of registers of information and invoices for medical care provided to an insured person in the process of using laser technologies in the treatment of diseases of the organ of vision should be carried out according to service code 2.78.46 “Contacting an ophthalmologist with the use of laser technologies for therapeutic purposes.” A special feature of visiting an ophthalmologist using laser technologies for therapeutic purposes is the presence of two visits, at least one of which must be about laser photocoagulation of the retina, which is necessarily reflected in the medical documentation. This service includes all necessary diagnostic examinations on the day of laser coagulation. The number of courses (stages), frequency of use and volume of intervention are determined individually by an ophthalmologist with mandatory indication in the primary medical documentation.

“TFOMS of the Volgograd Region” asks you to carefully read the procedure for generating accounts and strictly comply with the requirements of the Tariff Agreement. Heads of medical organizations need to take personal control over the implementation of volumetric indicators for outpatient medical care, bring this information to the attention of doctors and nursing staff who independently receive patients.

Outpatient clinical care

This is out-of-hospital medical care provided to people visiting a doctor at a clinic and at home. It is the most widespread and publicly accessible, and is of paramount importance for medical care to the population. Outpatient clinics are the leading link in the system of organizing health care; they include outpatient clinics and clinics that are part of hospitals and medical units, independent city clinics, incl. children's clinics, dispensaries, antenatal clinics, health centers, rural medical outpatient clinics and medical and obstetric centers.

Outpatient care includes preventive, therapeutic, diagnostic and rehabilitation measures aimed at reducing morbidity, disability and mortality. Important integral part at the same time are preventive examinations, Clinical examination, as well as hygienic education of the population and promotion of a healthy lifestyle.

To receive medical care on an outpatient basis, you must contact a medical organization at your place of residence or stay (local clinic). When exercising the right to choose a medical organization (attachment to a medical organization upon application) - to the selected medical organization.

Consultative and diagnostic assistance in advisory clinics is provided upon the referral of the attending physician of the territorial clinic.

Procedure and conditions for providing outpatient care to the population

1. Outpatient medical care is provided in outpatient clinics (or outpatient departments of hospitals), including at home when a medical professional is called, and does not provide for round-the-clock medical supervision and treatment.
2. To register a patient for an appointment with a doctor at a local clinic:
   • when contacting the clinic reception in person;
   • by recording via electronic registry(patients’ self-registration for doctor’s appointments via the Internet);
   • by phone, incl. multi-channel (self-registration of patients by telephone);
   • through terminals located in the lobby of the clinic (if available).
3. When providing medical care on an outpatient basis, the following order is allowed:
   • for scheduled patients to see doctors of main specialties (general practitioner, pediatrician, surgeon, obstetrician-gynecologist, dentist) - no more than 5 working days;
   • for consultations with specialist doctors (narrow) from registration of the date of application in the prescribed manner - no more than 10 working days;
   • for basic laboratory tests - no more than 7 working days, for studies of functional and radiology diagnostics- no more than 10 working days, for expensive diagnostic studies (CT, MRI) - no more than 25 working days.
4. Scope of diagnostic and therapeutic measures for a particular patient is determined by the attending physician in accordance with the Procedures for the provision of medical care, clinical recommendations and guidelines, and other regulatory legal documents. The patient must be informed about the scope of diagnostic and therapeutic measures.
5. In conditions life-threatening, or the impossibility of providing medical care in the conditions of this medical organization, the patient is sent to another medical organization for the next stage of medical care in accordance with the Procedures for the provision of medical care approved by the Ministry of Health Russian Federation.
6. In the presence of medical indications for consultation with a specialist and (or) laboratory - diagnostic study, absent in a given medical institution, the patient must be sent to another medical institution where these medical services are provided free of charge.

6.2. Organization of outpatient care for the urban population.

This type of assistance, as the most widespread and socially significant, occupies a leading place in the medical provision of the population. Outpatient care is most often provided in outpatient clinics and clinics.

Outpatient clinic – an institution that provides care to patients in one or more primary medical specialties.

In the clinic assistance is provided in many specialties.

Both in outpatient clinics and clinics, patients are treated when they contact these institutions, and preventive work is also carried out. In addition, they provide medical care at home.

A polyclinic differs from an outpatient clinic in the volume and level of medical and preventive care; in the latter it is provided by doctors of the main 4 - 5 specialties. Only family doctors (general practitioners) can also provide care in the outpatient clinic.

The importance of clinics and outpatient clinics is determined by their proximity to the population, as well as the possibility of optimal participation in the medical care of the vast majority of the population.

These institutions occupy a leading place in the preventive work of the health care system; their employees identify risk factors among the relevant populations, infectious and socially significant diseases.

The work of outpatient clinics and clinics greatly influences the activities of other healthcare institutions - hospitals, ambulance services. In addition, the level and duration of temporary disability, the frequency of complications of diseases and the consequences of their course, the level of hospitalization, the length of stay of patients in hospitals and, in general, the rational use of beds, as well as, to a large extent, the population’s assessment of the activities of all healthcare systems.

The main tasks of the city clinic:

provision of primary and specialized qualified medical care on an outpatient basis and at home;

carrying out dispensary observation of various contingents;

carrying out medical examination disability;

organization and conduct preventive measures, including anti-epidemic ones;

study of population health indicators.

During the period of reform of the healthcare system, the work of the clinic should be aimed at significantly increasing the quality of treatment of the population, a complete comprehensive examination of its socially significant groups, and full-fledged rehabilitation.

All these measures will help reduce the current rather high level hospitalization and will ensure the referral of patients to inpatient treatment in cases of emergency.

Main sections of the clinic:

preventive, including anti-epidemiological measures;

diagnostic and treatment;

organizational and methodological.

To preventive measures include both preventive (primary) and potentially preventive (secondary).

Primary activities:

grafting;

hygienic education of the population;

dispensary observation of healthy people and persons with risk factors;

sanitary and anti-epidemiological measures.

Secondary events:

timely determination infectious diseases and notification of an infectious patient to the SES;

organization of isolation of patients, monitoring of convalescent contacts;

organization of ongoing disinfection.

Treatment and diagnostic work includes:

early detection diseases and complete timely examination of patients;

treatment of patients in clinics and at home, including in hospitals at home, using an appropriate set of rehabilitation treatment methods;

provision of emergency medical care in case of a sudden deterioration in the patient’s health;

examination, selection and referral of patients for hospitalization;

selection and examination of patients for sanatorium-resort treatment;

conducting an examination of temporary disability;

selection and referral of patients with signs of permanent disability to MSEC.

Organizational and methodological work includes:

analysis of the health status of the population;

assessment of the activities of the clinic, its departments and personnel;

introduction of new effective methods and methods of prevention, diagnosis and treatment, as well as organizational forms and working methods;

organization and provision of advanced training for medical staff (direction for postgraduate training and internship in hospitals, holding scientific and practical conferences and seminars).

Structure of the city clinic:

City Polyclinic:

control;

economic part;

registry;

medical and auxiliary departments (physiotherapeutic, exercise therapy, reflexology);

diagnostic departments (X-ray department, laboratory, departments (offices) functional diagnostics, endoscopy room, ultrasound room);

first aid room;

treatment and preventive units (departments or rooms of 18-20 specialties);

prevention departments;

other divisions

emergency room;

office of accounting and medical statistics;

day hospital;

state accounting department.

In accordance with the decree of the Ministry of Health of Ukraine No. 127 dated May 21, 1998. instead of accounting rooms and medical statistics, information and analytical departments.

To ensure reception of the population in the clinic and provision of medical care at home doctor positions in cities with a population of more than 25 thousand. in city clinics, which are part of city hospitals (medical units with a hospital), are installed in accordance with the decree of the Ministry of Health of Ukraine No. 33 of February 23, 2000.

Staffing standards for doctors in city clinics

Job titles	Number of positions per 10 thousand. adult (15 years and older) urban population assigned to the clinic.
Local therapist
Cardiologist
Rheumatologist
Surgeon
Orthopedic traumatologist
Urologist
Otolaryngologist
Neuropathologist
Ophthalmologist
Endocrinologist
Infectious disease physician
Allergist, immunologist
Gastroenterologist
Pulmonologist

If the clinic has dermatovenerological, oncological or phthisiatric offices (departments), then a staff of specialist doctors is introduced to receive patients of a particular profile, who are determined according to the staffing standards of the corresponding office (department).

It should be noted that with the improvement of primary health care and the introduction of general practice (family medicine), the ratio of different specialists will change and the provision of doctors of certain specialties to the population will decrease, since family doctors must provide more than 80% of all requests for outpatient care.

The effectiveness of the clinic depends on the proper organization of the work of all its departments and medical staff. This concerns the development of optimal work schedules, regulation of the work of visitors, which is primarily done by senior officials, as well as the reception desk, the pre-medical office and the doctors themselves.

Registry task:

reference and information support;

preliminary and urgent appointments and house calls - telephone and direct patient applications;

regulation of the intensity of the flow of people (referral, if necessary, to the pre-medical office, prevention department, etc.) in order to create an even load of doctors;

registration and storage of medical documentation;

timely selection and delivery of medical documentation to doctors’ offices, in particular outpatient records (if they are stored in the clinic and not among residents).

Medical records in the clinic can be stored according to an alphanumeric system, by area and number medical records outpatient, sometimes by street, house and apartment numbers.

Activities for reducing queues at the registration desk, in particular, through the rational staffing of registrars, the distribution of their functions for maintaining records and selecting medical documents.

Reducing queues is facilitated by the availability of complete reference information (determining the location of sites, the names of doctors, their reception hours, the location of offices, the working hours of the clinic, treatment, diagnostic rooms and laboratories, the system of calling a doctor at home, etc.). It is also necessary to organize preliminary telephone appointments and self-appointments with doctors on all days of the week, receiving house calls by telephone, taking into account the work schedules of departments and specific specialists.

The immediate responsibilities of each registrar are determined by the head of the registry. The positions of medical registrars are established at the rate of one per 10 doctors who conduct outpatient visits.

Doctors' working hours The clinic should be:

• fixed at the start of each day of the week;

  dynamic in its duration, which depends on the need to allocate time for servicing house calls and for preventive work, from the seasonal increase in certain diseases.

A shift schedule involves the doctor working at different hours throughout the days of the week. This allows the population to see a doctor in their free time.

A significant part of visits to the clinic occurs at the beginning of the week and the first half of the day, which should be taken into account primarily by doctors when planning the time of repeat and dispensary visits.

In order to reduce the number of unnecessary visits to doctors, clinics are working pre-medical rooms, whose task is to issue referrals for examination, fill out the passport part in the direction to MSEC, sanatorium cards, and measure blood pressure. Experienced nurses are hired to work in pre-hospital rooms.

In a significant number of cases, the population turns first of all to the local doctor, who provides outpatient care on a local-territorial basis. The essence it consists of monitoring the assigned contingents of the territorial site and providing them with qualified medical care.

For maintaining the local principle the following conditions are required:

optimal population size of the site;

staffing the clinic with local doctors;

availability and compliance shift schedule work of doctors;

proper organization of the registry work.

Local therapist primarily provides primary health care (PHC), but its functions in its provision are limited compared to those that should be performed by a family doctor who provides patients with multidisciplinary treatment and preventive care and helps them in solving medical and social problems.

The local therapist sees patients in the clinic, visits them at home on calls or on his own initiative, provides dispensary observation for those who require it, and carries out an examination of work ability.

When visiting patients at the clinic, the doctor takes anamnesis, performs physical and instrumental examination, gives recommendations, carries out an examination of work ability, makes appropriate entries in the outpatient’s medical card.

In addition to the timely detection of health problems and provision of first aid to the population of his area, the doctor must, if necessary, provide emergency assistance in case of sudden deterioration in condition, injuries, regardless of the place of residence of the patients.

The responsibilities of the local therapist also include organizing, if necessary, timely hospitalization of patients after a comprehensive examination of them in the clinic.

If a patient needs consultation with the head of the department or other specialist doctors, the therapist must prescribe them and do everything necessary for a timely consultation.

A significant place in the work of a local therapist is occupied by preventive work (medical examinations, clinical examination of certain groups of the population, hygienic education, etc.).

The local therapist has obligations to timely detect infectious diseases and notify the SES about this. He also organizes the isolation of patients and ongoing disinfection at the source of the infectious disease, provides treatment for patients at home, monitors contacts, and conducts (organizes) dispensary observation of those recovering.

Improving the quality of medical care depends significantly on the ability to provide it at home. The volume of this assistance is influenced by the composition of the population by age and gender, morbidity characteristics, the possibility of conducting laboratory and instrumental studies at home, the timeliness of assistance and the quality of treatment, and the territorial location of the sites.

After visiting the patient at home on the day of the call, the doctor can subsequently, if necessary, visit him on his own initiative (active visit). After the patient’s condition improves, they are sent for appropriate procedures or for re-examination at the clinic.

If necessary, the doctor organizes his treatment in a home hospital, involving a local nurse, who carries out the appropriate assignments and monitors the patient’s health.

Carrying out organizational and methodological work, the local therapist studies and analyzes the health status of the population and the indicators of his work.

The staff of district nurses is established at the rate of 1.5 positions for each position of a district therapist (decree of the Ministry of Health of Ukraine No. 33 of February 23, 200).

District nurse assists the doctor during an outpatient appointment - prepares a workplace, checks the availability of the necessary documentation and the receipt of outpatient medical cards from the registry (if they are kept in the clinic and not by residents), if necessary, measures blood pressure, conducts thermometry, explains to patients the procedure for preparation to laboratory instrumental studies. She also fills out, under the supervision of a doctor, medical records (statistical coupons for registering the final diagnosis or outpatient coupons, emergency notifications about infectious diseases, certificates about temporary disability), and issues a referral for diagnostic examinations.

The organization and quality of work of district staff shapes the population’s opinion about medical care in general. The effective operation of this level of outpatient care significantly affects the satisfaction of the need for medical care.

The volume and quality of a doctor’s work is affected by the unevenness of the workload and the treatment of some patients who do not need the help of a doctor at the time of contact.

The unevenness of the load is determined by the seasonal characteristics of the disease with a therapeutic profile, fluctuations in the number of visits in different days weeks and hours throughout the day.

The complex and responsible functions of the local service require planning and coordination of its interaction with various departments of the clinic. This work is provided by Head of the therapeutic department.

This position is introduced if there are 6.5 - 9 positions of general practitioners in the clinic (instead of 0.5 doctor positions). If there are more than 9 general practitioners on staff, the position of the manager is established in addition to these positions, and in this case he is engaged only in his direct management functions.

When introducing the position of head in other departments, the number of positions for specialist doctors of a certain profile may differ. For example, in otolaryngology, ophthalmology and neurology departments, the position of head is introduced when the number of doctors in the relevant specialties is at least 3.0 (instead of 0.5 doctor positions).

Head of therapeutic and other departments of the clinic, manages the activities of all personnel, is responsible for the volume and quality of treatment and preventive work and the diagnostic process.

It provides:

provision of qualified medical and diagnostic care to patients in the clinic and at home;

drawing up optimal work schedules for department staff;

control over the volume, quality of diagnosis and treatment;

participation in the examination of temporary disability and monitoring its quality;

implementation into practice modern methods prevention, diagnosis, treatment and work organization;

timely detection and treatment of infectious patients;

planned hospitalization of patients;

control over the completeness and quality of maintaining accounting documents;

drawing up plans and reports;

organization of advanced training for the department's medical staff.

An important structural unit of the clinic is prevention department.

His main tasks:

conducting medical examinations for the purpose of early identification of patients and persons at high risk of disease;

organization, accounting and control of medical examinations;

participation in the development of primary and secondary prevention measures;

promotion of hygienic knowledge.

This department employs predominantly nursing staff on a permanent basis. Its work is supervised by the head of the department - a general practitioner, whose position is established in a clinic that serves 30 thousand or more adults (instead of 0.5 doctor positions).

Doctors of other specialties are invited to work in the prevention department, allocating a certain time in their schedule to conduct medical examinations. If a antenatal clinic is located at the clinic, it provides medical examinations for women. In another case, the structure of the clinic has examination room, for work in which one midwife position is allocated per shift per 30 thousand adult urban population. She must be trained in the specialties of oncology, gynecology and proctology.

The main tasks of a midwife are:

conducting examinations of women with their consent (regardless of age and illness), who were the first to visit the clinic during the year, with the aim of early detection of precancerous diseases and malignant neoplasms;

mandatory collection of smears from the vagina and cervical canal and their sending to a cytology laboratory;

referral of persons with identified pathology to appropriate specialists.

As part of the prevention department, it can act as a structural unit, men's examination room. It employs a paramedic trained in the specialties of oncology, urology and proctology. The purpose of creating this office is the early detection of precancerous diseases and malignant neoplasms.

The activities of the prevention department contribute to the implementation dispensary method, the essence of which is:

active identification of contingents that are subject to clinical examination and their registration;

full comprehensive examination of persons requiring this;

active treatment;

dynamic monitoring of health status;

development and implementation of disease prevention measures and prevention of complications.

Medical examination task:

maintaining the health of the healthy;

early identification of risk factors and initial forms diseases;

full examination and treatment of patients, improvement of the health of patients at risk;

reduction of morbidity with temporary loss of ability to work and disability;

increase in labor productivity.

The implementation of these tasks is aimed at preserving and strengthening the health of the population.

Contingents of medical examinations are divided into two groups: the first – healthy and persons with risk factors, the second – sick.

The selection of persons for dispensary observation is carried out for both medical and social reasons.

For contingents of the adult population who are subject to dispensary observation for medical reasons, relate:

persons who have risk factors;

patients with certain chronic diseases;

persons who are often and long-term ill.

For social reasons The following are subject to dispensary observation:

persons working in hazardous and hazardous industries;

workers of food, communal and children's institutions;

secondary school teachers;

persons with social risk factors.

Carrying out clinical examination requires a certain sequence.

Stages of medical examination:

Identification and formation of contingents for dispensary observation.

Accounting of contingents undergoing clinical examination.

Comprehensive examination of persons subject to medical examination.

Dispensary observation and health improvement of the relevant contingents.

Assessing the effectiveness of clinical examination and carrying out organizational and methodological measures, improving its organization and quality.

The effectiveness of clinical observation is influenced by:

application of all necessary prevention methods, diagnosis and treatment;

coordination of the activities of doctors of relevant specialties;

proper socio-economic living and working conditions.

The selection of contingents for dispensary observation is carried out using:

appeals to health care facilities;

mass and individual medical examinations;

examinations of persons in contact with infectious patients.

In healthcare facilities, targeted, preliminary and periodic medical examinations are carried out.

Targeted medical examinations carried out to detect certain diseases on early stages(tuberculosis, neoplasms, etc.).

Preliminary medical examinations are carried out for the purpose of examining certain contingents during recruitment and training.

In accordance with Article 31 of the Fundamentals of Ukrainian Legislation on Health Care (1992), the Cabinet of Ministers of Ukraine, by Resolution No. 532 of August 5, 1994, approved the list of categories of the population that annually undergo mandatory medical examinations at the expense of budgetary funds:

teenagers aged 15-17 years;

vocational school students;

university students;

war veterans; persons who have special services to the Motherland;

labor veterans; persons who have special services to the Motherland;

persons who suffered as a result of the Chernobyl disaster.

Conducting medical examinations of persons who work at food enterprises, enterprises providing sanitary and hygienic services to the population, health care facilities and other enterprises, as well as drivers of individual vehicles, is carried out on a self-supporting basis or at the expense of special means. For this purpose, the staff of one of the city clinics (city administrative district) that performs this work establishes positions for doctors (therapist, etc.) at the rate of one position per 5,000 people subject to mandatory medical examination.

Medical examinations can be individual or mass. Mass examinations (periodic and targeted) are carried out among organized groups of the population. The forms of their implementation for different population groups may vary in frequency and composition of doctors.

After the medical examination, its results are analyzed, and those examined receive the necessary recommendations. Based on health assessment, they are divided into appropriate health groups:

TO Igroup - healthy - include individuals who do not have a history of chronic diseases or dysfunctions individual organs and systems. During the examination, no deviations from the norm were found.

Co. IIgroup– practically healthy – include persons who have a history of acute or chronic disease that does not affect the functions of vital organs and performance.

TO IIIgroup relate patients with chronic diseases. They are divided into patients.

In the domestic healthcare system, as already mentioned, there is outpatient care to the population(from lat. ambulatory- mobile). Outpatient clinics are designed to provide assistance to incoming patients, as well as patients at home.

A brief historical outline of the development of outpatient care in Russia

For the first time, outpatient care for patients in Russia began to be used in the 11th century. In 1089, in Kievan Rus, “free healing” for visiting patients was made the responsibility of “hospitals located at churches.” Outpatient “reception” of patients was also carried out by healers and healers, to whom ordinary people turned for help. Until the 16th century. medical affairs were not subject to the jurisdiction of the state, since Rus' was fragmented into feudal principalities, on the territory of which, although sanitary and quarantine measures were introduced (under the control of a prince or monastery), both Russian and foreign doctors were invited to serve, there was no single organization or health service was. And only after the creation of a centralized Russian state under the rule of Moscow became possible the organization of state medical institutions and publication of relevant regulations on medical matters. Thus, by decree of Ivan the Terrible, the so-called Tsareva, or Court, pharmacy was established (1581), which performed the functions of providing medical assistance to the tsar, his family, and fellow boyars. Soon the Pharmacy Order for Management was established medical affairs states.

In 1620, the first secular outpatient clinics appeared, where doctors treated patients. The organization of outpatient care was accelerated by severe epidemics of smallpox, plague, and cholera.

Peter's reforms gave rise to the reorganization of the entire medical business: instead of the boyar order system, a state administration was created, including the Medical Office instead of the Pharmacy Order. In 1738, the position of a doctor for the poor was established at the main pharmacy of St. Petersburg; this was the first free outpatient clinic in Europe.

In 1804, for the first time in the history of Russia, outpatient practice was introduced into the teaching program in medical faculties universities. As a rule, outpatient care in cities was provided at hospitals. Independent institutions of this type began to develop only in the 80s. XIX century, which was facilitated by the development of zemstvo and factory medicine.

The zemstvo reform created a system of medical care, including local service, traveling medical assistance, provision of paramedics.

Outpatient care has received intensive development in our country since the 20s. XX century, i.e. during the formation years of the domestic healthcare system. Thus, by agreement of the People's Commissariat of Health of the RSFSR and the All-Union Central Council of Trade Unions, medical aid stations, outpatient clinics, and hospitals began to be created at enterprises. In 1929, the Decree of the Central Committee of the All-Union Communist Party of Bolsheviks “On medical care for workers and peasants” was published, in which the main attention was paid to the organization of medical care, including outpatient care. Medical examination was declared an important method of prevention, which at that time, due to many objective reasons, was reduced to registration of diseases and medical examinations. The system of maternal and child health care has been improved, and the network of children's clinics and antenatal clinics has increased significantly. On the eve of the war, despite mistakes and miscalculations, repressions that claimed thousands of lives of healthcare professionals, a state healthcare system was built, which assumed a preventive focus, planning, accessibility, etc. By 1950, even taking into account the enormous damage caused to the national economy of the country during the war (40,000 hospitals and clinics were destroyed), the number of medical institutions not only reached pre-war levels, but also increased. In those years, medical examinations began to be carried out rural population, preparations are underway for medical examination at the clinic. From 1961 to 1983, outpatient care focused on clinical examination.

Organization of work of clinics and outpatient clinics

Currently, outpatient care is provided in a wide network of outpatient clinics and clinics that are part of hospitals, in independent city clinics and rural medical outpatient clinics, dispensaries, specialized clinics, antenatal clinics, health centers, first aid stations, etc. In these In institutions, approximately 80% of all patients begin and complete treatment, and only 20% of patients are subject to hospitalization.

Thus, outpatient care is the most widespread type of treatment and preventive care for the population.

The types of out-of-hospital care institutions were approved in 1978 by the USSR Ministry of Health. The leading ones are clinics and outpatient clinics.

Clinic(from Greek polis- city ​​and clinic- healing) is a multidisciplinary medical and preventive institution designed to provide medical, including specialized, care to patients, and, if necessary, to examine and treat patients at home.

The clinic sees doctors of various profiles (therapists, cardiologists, gastroenterologists, ophthalmologists, surgeons, etc.), and also has diagnostic rooms (X-ray, endoscopic, laboratory, physiotherapy room, etc.).

The basic principle of the clinic is territorial-precinct, when a local general practitioner and nurse are assigned an area with a certain number of residents. The local doctor and nurse are responsible for carrying out all therapeutic and preventive measures in the territory of this site. The territorial-precinct principle is also observed in relation to doctors of “narrow” specialties when they make house calls (as prescribed by the local therapist).

Outpatient clinic - This is a medical and preventive institution, which, like a clinic, is intended to provide medical care to patients coming to the outpatient clinic and to patients at home.

The operating principle of an outpatient clinic is also local, but an outpatient clinic differs from a clinic in that it has a smaller volume of work and capabilities. In outpatient clinics, located, as a rule, in rural areas, appointments are provided for only a small number of specialties (no more than five): therapy, surgery, obstetrics and gynecology, pediatrics. Job nurse in an outpatient clinic resembles the work of a district nurse in a clinic, but only an outpatient nurse is more independent.

Main tasks of the clinic are:

• provision of qualified specialized medical care to the population in clinics and at home;
• organizing and conducting medical examinations of the population;
• organization and implementation of preventive measures among the population in order to reduce morbidity, disability, and mortality;
• examination of temporary disability;
• organizing and carrying out work on sanitary and hygienic education of the population, promoting a healthy lifestyle.

Polyclinics can be independent or combined with a hospital, general or specialized, for example dental, spa, etc.

Main structural units of the city clinic

IN composition of the clinic includes the following divisions:

• registry;
• prevention department;
• medical departments;
• diagnostic department (laboratory, x-ray room, ultrasound diagnostic room, etc.);
• statistical office;
• administrative divisions (chief physician, deputy chief physician for examination of work capacity).

Registry ensures registration of patients for appointments with doctors and registration of doctor's house calls, timely selection and delivery of documentation to doctors' offices, information to the population about the time of doctors' appointments and the rules for calling a doctor at home, preparation of sheets and certificates of temporary disability.

Prevention department includes a pre-medical control room, a women's examination room, etc. Patients from the registry who come to see a doctor for the first time are sent to the prevention department. In the pre-medical control room, patients are systematized, various certificates are issued, and preliminary examinations are carried out.

IN composition of medical departments includes local therapists and doctors of “narrow” specialties. Each department is headed by a department head. The head of the clinic is the chief physician of the clinic (the clinic is an independent medical and preventive institution) or the deputy chief physician of the clinic (when the clinic is combined with a hospital).

IN statistical office polyclinics process and record documentation, analyze the performance indicators of the structural divisions of the polyclinic.

Organization of the work of a local therapist in a city clinic

Local therapist plays a leading role in the public health system (in the future this will be a family doctor). IN difficult work The local doctor combines medical and organizational activities (organization of prevention, treatment, medical examination, rehabilitation, sanitary and educational work). A local doctor is essentially a front-line healthcare organizer.

It is the activities of the local general practitioner and local nurse that most closely come into contact with the work of organs social protection and is largely medical and social. The local doctor and local nurse have an important influence on solving the client’s medical and social problems in professional activity social worker. It is the local doctor who, if necessary, should be contacted by a social work specialist in case of difficulties of a client’s medical and social nature.

The work of a local general practitioner is usually organized in such a way that every day he sees patients in the clinic (about 4 hours) and makes calls to patients at home (about 3 hours). The doctor not only carries out calls made by the patient himself or his relatives, but also, if necessary (without calling), visits the patient at home. These calls are called active calls. The local doctor should visit chronically ill patients, lonely elderly people, and the disabled at least once a month, regardless of whether the patient called the doctor or not. When performing a call, the doctor not only treats the patient, but also performs elements social work: finds out the social and living conditions of the patient, contacts, if necessary, with social protection authorities, the RCCS department, pharmacies, etc.

The nurse is also directly involved in the reception of patients (prepares the documentation necessary at the reception, writes prescriptions for medications as directed by the doctor, fills out referral forms for examination, measures blood pressure, body temperature, etc.) and carries out doctor’s orders at the site ( makes injections, puts mustard plasters, enemas, checks the patients’ compliance with the prescribed regimen, etc.). If necessary, the activities of the doctor and nurse at the site can be organized as a hospital at home, when the doctor visits the patient at home every day, and the nurse carries out medical prescriptions at home.

Clinical examination

Clinical examination is the main means of prevention in domestic system healthcare.

Clinical examination is an active, dynamic monitoring of the health status of certain populations (healthy and sick), registering population groups for the purpose of early detection of diseases, periodic monitoring and complex treatment sick, improving the health of work and life, to prevent the development of the disease, restore ability to work and prolong the period of active life.

Clinical examination involves examination and treatment of patients without exacerbation of the disease.

Clinical examination (or clinical examination method) consists of several stages. At the registration stage, patients are identified (based on the results of medical examinations or by referral, with the former being preferable). At the next stage, the patient is examined, his state of health is assessed, and working and living conditions are studied. At the third stage, a plan of preventive and therapeutic measures is drawn up and documentation is drawn up. Then the patient is actively and systematically monitored, individual preventive treatment, recreational activities at the execution stage. Sanitary educational work, the formation of a healthy lifestyle, state and public measures to combat health risk factors are carried out at the final stage (preventive measures).

Outpatient medical care (lat. ambulatory - mobile, walking; Greek polis - city, clinic- the art of healing, caring for bedridden patients) is carried out outside of hospital conditions.

Currently, about 80% of patients are provided with medical care in outpatient clinics. The outpatient clinic link (the so-called first contact zone) provides for the examination and treatment of patients at the clinic and, if necessary, at home, as well as clinical examination (health monitoring) of the population.

The principle of operation of the outpatient clinic is territorial and local (main structural element outpatient clinic level of healthcare - territorial therapeutic area), which implies the permanent assignment of a certain number of residents of the corresponding area to the local general practitioner and nurse.

The goals and objectives of the outpatient clinic are the following:

Qualified medical care in the clinic and at home.

Clinical examination.

Preventive measures (reducing morbidity, disability and mortality).

Examination of temporary disability.

Sanitary and hygienic education of the population.

Outpatient clinic(lat. ambulatory - mobile, walking) is a medical and preventive institution designed to provide out-of-hospital medical care to the population of a small urban village, a small industrial enterprise or a rural area. In the countryside outpatient care can be provided by feldsher-midwife stations, which are the main structural unit of rural healthcare. The local principle of work makes it possible to actively identify patients, provide them with qualified medical care, study morbidity, and carry out preventive and sanitary educational work.

An outpatient clinic differs from a clinic in a certain limitation of the medical care provided and a small number of staff (as well as the number of patients served). As a rule, an outpatient clinic is located in a rural area and provides services to the population with the required minimum number of specialists (no more than five) - a therapist, a surgeon, an obstetrician-gynecologist and a pediatrician.

Medical units provide medical care at large industrial enterprises. They may include a hospital, a clinic, a health center and a dispensary.

Health center- a unit of a medical unit or clinic, organized at industrial enterprises, construction sites, higher and secondary educational institutions, schools. Along with providing first aid for injuries, sudden illnesses and poisonings, the health center carries out planned sanitary, hygienic and therapeutic measures to prevent and reduce morbidity. A medical health center is headed by a doctor, a paramedic health center is headed by a paramedic or a nurse.

Women's consultation- a medical and preventive institution that provides treatment and prevention of gynecological diseases, as well as monitoring of pregnant women. A mid-level medical worker - a midwife - assists the doctor during appointments, provides patronage to pregnant women, and teaches them how to care for newborns and personal hygiene. The midwife carries out doctor's orders and carries out health education work.

Ambulance stations provide the population with medical care in emergency situations, working around the clock. The team can be led by a paramedic who independently responds to calls, provides first aid and hospitalizes patients. Specialized medical care, which requires higher qualifications, is provided by a team led by a doctor, and a paramedic assists him in providing assistance and transporting patients. Many ambulance stations have vehicles with modern equipment, which makes it possible to provide emergency highly qualified and specialized assistance and carry out resuscitation measures at home and on the way to the hospital.

Additionally, it should be noted that modern domestic healthcare pays great attention to the service of a family doctor (general practitioner) as a promising link in the provision of primary health care. Order of the Ministry of Health of the Russian Federation No. 237 (dated August 26, 1992) provides for the creation of special medical offices (premises) of family medicine, equipped with modern diagnostic equipment, and regulates the staff of such a family medicine office (a family doctor and three paramedical workers, including including laboratory assistant and paramedic). In fact, the general practitioner acts as the legal successor of the local therapist.

Inpatient medical care

If the patient’s condition requires systematic monitoring, the use of complex diagnostic and treatment procedures, and specialized medical care, he is sent to a hospital-type hospital.

Hospital (lat. stationarius - standing, motionless) - structural subdivision medical and preventive institution (hospital, medical unit, dispensary), intended for examination and treatment of patients in a 24-hour environment (with the exception of day hospital) their stay in this institution under the supervision of medical personnel.

Day hospital- an intermediate link between outpatient and inpatient medical care. This is an inpatient-substituting form of organizing medical care for the population, a structural unit of an outpatient clinic or hospital institution, designed to provide therapeutic, rehabilitation, diagnostic and preventive measures to patients who do not require round-the-clock medical supervision during the daytime.

Dispensary(lat. dispense- distribute) - a special specialized treatment and preventive institution operating according to the dispensary method. The dispensary is intended for active early detection and registration of patients with certain groups of diseases, systematic dynamic monitoring of them, provision of specialized medical care, development of recommendations for improving the health of work and life of these patients, as well as for the study of morbidity and its causes, development and implementation of preventive measures diseases, carrying out sanitary and educational work.

Thus, a dispensary is an independent specialized medical and preventive institution designed to provide medical and preventive care to a certain group of patients. Currently, the domestic healthcare system provides the following types of dispensaries: cardiology, anti-tuberculosis, oncology, dermatovenerological, psychoneurological, narcological, anti-goitrous, endocrinological, medical and physical education.

The goals and objectives of the dispensary are the following::

Active early identification of patients of the relevant profile.

Monitoring of identified patients (patronage).

Specialized medical care.

Rehabilitation of patients.

Prevention of disease.

Study of morbidity and conditions for the development and spread of the disease.

Sanitary educational work.

The importance of patient care cannot be overestimated. Accurate implementation of the doctor’s instructions, carrying out all activities that help preserve and restore the patient’s strength, alleviate his suffering, carefully monitor the functions of all organs, prevent possible complications, sensitive attitude towards the patient - all this is included in the concept of caring for the patient. And if the doctor treats, then the nurse takes care of you.

Strict compliance with doctor’s instructions, strict adherence to dietary, drinking and hygienic regimes, creation of favorable physical and psychological conditions can restore health even in seemingly hopelessly ill people, and, conversely, poor care, careless attitude The addition of a nurse to their duties can not only delay the patient’s recovery, but also aggravate the severity of his condition.

IN Everyday life caring for a patient is understood as providing assistance to him in meeting various needs: food, drink, toilet, movement, physiological functions, etc. Care also means creating for the patient optimal conditions stay in medical institution or at home: peace and quiet, comfortable bed, clean linen, Fresh air etc. This amount of care is usually carried out by juniors. medical personnel and relatives of the patient. F. Nightingale wrote: “If, through proper care, all conditions complicating the disease are eliminated, then the disease will take its natural course, and everything collateral, artificial, caused by mistakes, frivolity or ignorance of others will be eliminated.”

In medicine, the concept of “patient care” is interpreted more broadly. Here he stands out in independent discipline and represents a whole system of measures, including the correct and timely implementation of various medical prescriptions, carrying out diagnostic measures, preparing the patient for certain studies, monitoring the patient’s condition, providing first aid first aid, maintaining the necessary medical care. documentation.

Patient care influences the effectiveness of treatment and is an integral part of it. The quality of patient care is inextricably linked with the results of treatment of the disease and its prognosis. Thus, with successful management of a patient with myocardial infarction, you can “lose” the patient due to unscrupulous performance necessary measures care: for example, lack of constant supervision may result in the patient violating strict bed rest in the first days of myocardial infarction and the development, in particular, of complications such as fatal cardiac arrhythmias and progression of heart failure. Another example: inadequate control over the cleanliness of bed linen and the condition skin in conditions of physical inactivity can lead to the formation of bedsores. That is why patient care is an essential component of treatment, influencing the course of the disease and the patient’s recovery.

There are two main areas of care for patients - general and special care:

· General care- implementation general events care, regardless of the nature of the disease ( general examination, measuring body temperature, changing linen, etc.).

· Special care - implementation of specific care measures depending on the diagnosis of the disease (for example, preparing the patient for cholecystography, catheterization of the bladder).