Health care facility stampApproved by Order of the Ministry of Health
And social development Russian Federation
dated January 31, 2007 N 77
Medical documentation
Form N 088/у-06DIRECTION
on medical and social examination organization providing
therapeutic preventative care
Date of issue “______” ___________________________ 20_____
1. Last name, first name, patronymic of the citizen sent for a medical and social examination (hereinafter referred to as the citizen): Ivanov Viktor Alexandrovich
2. Date of birth: 07/11/1948.
3. Gender: male
4. Last name, first name, patronymic of the citizen’s legal representative (filled in if there is a legal representative):__________________________________________________________________________
5. Address of the citizen’s place of residence (if there is no place of residence, the address of stay, actual residence on the territory of the Russian Federation is indicated): Russian Federation, 000000, N-skaya region, N-sky district, N-sky, st. Gulagskaya, 1, GBUSONO "N-sky PNI"
6. Is not disabled, disabled person first, second, third groups, category “disabled child” (underline as appropriate).
7. Degree of loss of professional ability in percentage: __________________________
(to be filled in when re-referring)
8. Directed primarily, again(Underline whatever applicable).
9. Who does he work at the time of referral for medical and social examination: does not work
(indicate the position, profession, specialty, qualification and length of service for the specified position, profession, specialty, qualification; in relation to unemployed citizens make a note: “doesn’t work”)
10. Name and address of the organization in which the citizen works: does not work
11. Conditions and nature of the work performed: does not work
12. Main profession (specialty): driver, tractor driver
13. Qualification in the main profession (class, rank, category, title): No
14. Name and address educational institution: No
15. Group, class, course (underline what is indicated): No
16. Profession (specialty) for which training is provided: No
17. Observed in organizations providing medical and preventive care, with 2005 of the year.
18. History of the disease (onset, development, course, frequency and duration of exacerbations, treatment and rehabilitation measures taken and their effectiveness):
In 2005, he suffered a traumatic brain injury and was treated as an inpatient with a diagnosis of brain contusion. For 20 years he abused alcohol, long-term binges with severe withdrawal symptoms, for which he was repeatedly treated in hospital. Changed mental condition- began to leave home on long time, wandered, got lost. He became tearful, sentimental, lost his hygiene skills, spent a lot of time in bed, and became indifferent to his relatives. At the same time, he expressed unrealistic plans for the future, which he immediately forgot about. Due to an increase in emotional-volitional defect and behavioral disorders, he was repeatedly hospitalized in the mental hospital in Nsk. The first medical and social examination was carried out on November 18, 2013. During the period between ITUs, the mental state showed negative dynamics. The last hospitalization in PND No. 1 in Nsk was from April 3, 2014. to June 20, 2014, discharged with the diagnosis: “ Organic disorder individuals in connection with mixed diseases(TBI, intoxication) with cognitive impairment. Astheno-neurotic syndrome." In PND No. 1 in N-ska he received treatment: phenibut, vinpocetine, pentoxifylline, lobster, and during treatment the emotional background somewhat leveled out. After discharge, for social reasons, he was transferred to the N-sky PNI. In the boarding school he is passive, spends time in bed, does not take care of himself, does not go to the dining room himself, and washes himself with a reminder. Takes medication under the supervision of staff: piracetam, cinnarizine, betahistine, thioryl, combilipen, cavinton, phenazepam, azaphen. The patient's relatives do not visit. Needs to outside help and care.
________________________________________________________________________________________
(described in detail at primary direction; when re-referring, the dynamics for the period between examinations are reflected, new cases of diseases identified during this period that led to persistent impairment of body functions are described in detail)19. Life history (past illnesses, injuries, poisonings, surgeries, diseases that are hereditary are listed; in addition, in relation to the child, it is indicated how the mother’s pregnancy and childbirth proceeded, the timing of the formation of psychomotor skills, self-care, cognitive and play activities, neatness and personal care skills, how it proceeded early development(by age, behind, ahead)):
Born in Nsk. The younger of two brothers. Heredity is not psychopathologically burdened. He grew up, developed according to his age, attended nurseries preschool institutions. I went to school at the age of 7 and graduated from 10th grade. Served in the army. He graduated from driving courses, worked as a bulldozer driver, tractor driver, and driver. He was married twice and has an adult son. Lived with his elderly mother. Family ties have been lost. Pensioner. Socially maladjusted. On June 20, 2014, he was admitted to live at the N-sky PNI by transfer from the PND No. 1 in N-sk.
_______________________________________________________________________________________
(to be completed upon initial referral)20. Frequency and duration of temporary disability (information for the last 12 months):
№
Date (day, month, year) of the beginning of temporary disability
Date (day, month, year) of the end of temporary disability
Number of days (months and days) of temporary disability
Diagnosis21. Results of the activities carried out on medical rehabilitation in accordance with the individual rehabilitation program for a disabled person (to be filled in when re-referring, specific types are indicated rehabilitation therapy, reconstructive surgery, spa treatment, technical means medical rehabilitation, including prosthetics and orthotics, as well as the time frame within which they were provided; body functions that were able to be compensated or restored in whole or in part are listed, or a note is made that positive results missing):
Medical rehabilitation activities without positive effect. He received treatment with nootropic and vasoactive drugs, vitamins, tranquilizers, and antidepressants according to indications in various doses.22. State of a citizen when referred for a medical and social examination (indicate complaints, examination data by the attending physician and doctors of other specialties):
Examined by a psychiatrist: His posture is hunched, he moves independently, hesitantly, he uses glasses. Dresses and eats independently. Outwardly somewhat sloppy. Consciousness is not darkened. Disoriented in place, in time, believes that it is now 1948. He is oriented correctly in his own personality. Available to contact. He misunderstands many questions and asks again. He interrupts the doctor, tries to tell him how difficult his life is, refers to his helplessness, complains that no one is treating him. Makes complaints about general weakness, dizziness. Requires bed rest, then rudely refuses this opportunity. Emotionally unrestrained, easily affected. Irritated, he answers the question about his health with anger: “How can a sick person feel?!” Intelligence, memory with a significant decrease. Thinking is slow in pace, viscous, unproductive. Finds words with difficulty and quickly becomes exhausted in conversation. Volitional abilities are significantly weakened. In the department, he spends time in bed, refuses to go to the canteen because he is afraid of getting lost, and rudely refuses outside help: “bring food to the ward.” The background mood is reduced. Denies the presence of suicidal thoughts. He is not critical of his condition and the current situation. No active psychoproduction is detected. Sleep and appetite are not affected. Controls physiological functions.
________________________________________________________________________________________
________________________________________________________________________________________23. Results additional methods research (the results of laboratory, radiological, endoscopic, ultrasound, psychological, functional and other types of studies are indicated):
UAC dated 10.23.14.:Hb=131g/l, WBC=5.7x109/l, ESR=5mm/h
OAM from 06.11.14.:Ket=no, Glu=no, Lev=no
FY from 11/18/14.:Lungs and heart are normal
ECG dated October 31, 2014.: Sinus rhythm, normal ECG
Circle chest 85 cm,waist circumference 80 cm,hip circumference 87 cm.
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________24. Body weight: 59 kg., height: 1,68 m., body mass index: 20,9 .
25. Evaluation physical development: normal, deviation (underweight, overweight, short stature, high growth) (Underline whatever applicable).
26. Assessment of psychophysiological endurance: norm, deviation(Underline whatever applicable).
27. Evaluation emotional stability: norm, deviation(Underline whatever applicable).
28. Diagnosis upon referral for medical and social examination:
A) code of the underlying disease according to the ICD: F07.08
B) underlying disease: Severe organic personality disorder due to mixed diseases (TBI, intoxication) with cognitive impairment. Persistent social and labor disadaptation.
Therapist: Chronic toxic (alcoholic) hepatitis in remission.
Neurologist: Dyscirculatory encephalopathy stage III.combined genesis.Astheno-neurotic syndrome.
Oculist: Retinal angiopathy of both eyes.
D) complications: ________________________________________________________________________________
________________________________________________________________________________________29. Clinical prognosis: favorable, relatively favorable, doubtful
30. Rehabilitation potential: high, satisfactory, short(Underline whatever applicable).
31. Rehabilitation prognosis: favorable, relatively favorable, doubtful(undefined), unfavorable (underline as appropriate).
32. Purpose of referral for medical and social examination (Underline whatever applicable): to establish disability , degree of loss of professional ability as a percentage, for the development (correction) of an individual rehabilitation program for a disabled person (disabled child), rehabilitation programs for victims of industrial accidents and occupational disease, for another (specify): ________________________________________________
________________________________________________________________________________________33. Recommended measures for medical rehabilitation for the formation or correction of an individual rehabilitation program for a disabled person (disabled child), a rehabilitation program for a victim of an industrial accident or occupational disease:
1. Constant observation by a psychiatrist.
2. Drug treatment: nootropics, vasoactive drugs, tranquilizers, antidepressants according to indications.
3. Rational occupational therapy for the development and maintenance of everyday self-care skills.
(specific types of rehabilitation therapy are indicated (including drug provision in the treatment of a disease that has caused disability), reconstructive surgery (including medication provision in the treatment of a disease that has caused disability), technical means of medical rehabilitation, including prosthetics and orthotics, a conclusion on spa treatment with a prescription of the profile, frequency, duration and season of recommended treatment, the need for special medical care persons injured as a result of industrial accidents and occupational diseases, about the need for medicines for the treatment of consequences of industrial accidents and occupational diseases, other types of medical rehabilitation)
Chairman medical commission:
Members of the commission:
- Form N 088/у-06.
- Referral for medical and social examination by an organization providing medical and preventive care.
Recommendations for the procedure for filling out registration form No. 088/u-06 “Referral for medical and social examination by an organization providing medical and preventive care”
The line “Date of issue” indicates the date of issue of the “Referral for a medical and social examination by an organization providing medical and preventive care” to the citizen referred for a medical and social examination or his legal representative.
Form n 088/u-06 referral for medical and social examination by an organization providing treatment and preventive care, order of the Ministry of Health and Social Development of the Russian Federation dated 01/31/2007 77 (as amended on 10/28/2009) on approval of the form of referral for medical and social examination by an organization providing therapeutic and preventive care (2017). Current in 2017 | The law is simple!
APPROVED
- APPROVED Order of the Ministry of Health. Donetsk People's Republic.
- page 2 of form No. 088/у. 13. Change of profession or working conditions for Last year: 14. The patient’s condition upon referral to MSEC (data from an objective examination by a specialist.
On approval of the Rules for conducting medical and social examination
- Preamble as amended by the order of the Minister of Health and Social Development of the Republic of Kazakhstan dated
- the following documents: 1) referral for medical and social examination (hereinafter referred to as form 088/u)
- Republic of Kazakhstan dated November 23, 2010 No. 907 “On approval of the form...
www.info.mintrud.kz
Application
- Appendix to the Order of the Ministry of Health and Social Development of the Russian Federation dated January 31, 2007 No. 77.
- Medical documentation. Form No. 088/у-06.
- Referral for medical and social examination by the organization...
www.invalidnost.com
Form No. 088/у-06
Appendix to the Order of the Ministry of Health and Social Development of the Russian Federation dated January 31, 2007 No. 77. Download Form No. 88/у-06 (.doc). Medical documentation. Form No. 088/у-06.
On approval of the Rules for conducting medical and social examination - IPS "Adilet"
- 1) referral for medical and social examination (hereinafter referred to as form 088/u), approved by order of the Acting Minister of Health of the Republic of Kazakhstan dated November 23, 2010 No. 907 “On approval of forms of primary medical documentation...
“Referral for medical and social examination by an organization providing medical and preventive care”
The line “Date of issue” indicates the date of issue of the “Referral for a medical and social examination by an organization providing medical and preventive care” to the citizen referred for a medical and social examination or his legal representative.
On line 1 the surname, name, and patronymic of the citizen sent for a medical and social examination are indicated in full.
On line 2“Date of birth” indicates the day, month and year of birth.
On line 3 The gender of a citizen is indicated in abbreviation: “m” or “f”.
Line 4“Last name, first name, patronymic of the legal representative of the citizen” is filled in completely if there is a legal representative.
On line 5“Address of the citizen’s place of residence”, in the absence of a place of residence, indicates the address of residence, actual residence on the territory of the Russian Federation.
On line 6“Not a disabled person, a disabled person of the first, second groups, category “disabled child” group” indicates the disability group based on the disabled person’s certificate from a medical institution social expertise about the established disability group or emphasizes “not disabled” if the patient is referred for the first time.
Line 7“The degree of limitation of the ability to work” was excluded by the Decree of the Government of the Russian Federation of December 30, 2009. N 1121
Line 8“The degree of loss of professional ability in percentage” is filled in during re-examination on the basis of a certificate available to the citizen from a medical and social examination institution on determining the degree of loss of professional ability.
On line 9 it is emphasized whether the citizen is referred initially or repeatedly to the ITU.
On line 10“Who works at the time of referral for medical and social examination” should indicate the position, profession, specialty, qualification and length of service in the specified position, profession, specialty, qualification; for non-working citizens, make an entry: “not working.”
On line 11“Name and address of the organization in which the citizen works” indicates the name of the organization with the address in which the person being sent works on the day of opening the certificate of incapacity for work. If a citizen does not work, a corresponding entry is made about this.
On line 12“Conditions and nature of the work performed” information is recorded from the patient’s words, in necessary cases are requested from the place of work in the form production characteristics(working hours, shifts; manual, machine-manual, mental, conveyor work: working position (percentage: sitting, standing, alternating, walking); degree of physical stress: constant (light, moderate, heavy) and temporary (light , moderate, severe); degree of neuropsychic stress: permanent (mild, moderate, severe) and temporary (mild, moderate, severe); administrative and economic work (large, medium, small volume), indicate the number of subordinates; presence of unfavorable working conditions (work in a hot shop, in the cold, increased dust and gas contamination, exposure to chemical substances, at height, with vibration).
On line 13“Main profession (specialty)” indicates the profession obtained through special education(for example, engineer, teacher, construction technician), or a profession in which there is the longest work experience and (or) the highest qualifications (for example, V-category repairman, etc.).
On line 14“Qualification in the main profession (class, rank, category, rank)” should indicate the qualifications that the patient had on the day of opening the certificate of incapacity for work.
Lines 15, 16. 17 are filled out for citizens who are studying at an educational institution at the time of referral for a medical and social examination (full-time or part-time). Line 15 indicates the name and address of the educational institution, line 16 indicates the indicated group, class, course, line 17 indicates the profession (specialty) that a citizen sent for a medical and social examination will receive upon graduation from the educational institution.
On line 18“Observed in organizations providing medical and preventive care since _____ year” indicates the date of initial filling outpatient card patient in a medical institution.
On line 19 during the initial registration of a referral for a medical and social examination, information about the onset of the disease (the nature of the injury, injury), features of the course, exacerbations (indicate the frequency and duration of exacerbations for the 12 months preceding the referral of the patient for a medical and social examination), information about the nature of the treatment (outpatient or inpatient, indicating the department's profile), types of treatment: therapeutic, surgical, physiotherapeutic, etc. When making a referral for re-examination, information about the course of the disease for the period that has passed since the date of establishment of the disability group is indicated, new cases identified during this period are described in detail diseases that lead to persistent impairment of body functions.
Line 20“Life history” is filled out during the initial referral. Diseases suffered in the past, injuries, poisonings, operations, diseases for which heredity is aggravated are listed. In relation to the child, it is additionally indicated how the mother’s pregnancy and childbirth proceeded, the timing of the formation of psychomotor skills, self-care, cognitive and play activities, neatness and self-care skills, how development proceeded (by age, with a lag, with an advance).
On line 21“Frequency and duration of temporary disability for the last 12 months” in the columns “Date (day, month, year) of the beginning of temporary disability” and “Date (day, month, year) of the end of temporary disability” indicate the dates of opening and closing certificates of incapacity, in the column “number of days (months and days) of temporary disability” indicates the total number of days of temporary disability. If the patient does not work, then this section indicates the frequency of calls for him medical care to a medical institution and diagnosis of diseases for which the patient applied to a health care facility. The column “Diagnosis” indicates the diagnosis of the disease for which the patient was recognized as temporarily disabled during the corresponding period or sought medical help.
On line 22“The results of measures taken for medical rehabilitation in accordance with the individual rehabilitation program for a disabled person” indicate information about measures to restore the patient’s ability to work, specific types of rehabilitation therapy, reconstructive surgery, sanatorium treatment, technical means of rehabilitation, including prosthetics and orthotics, as well as the time frame within which they were provided; body functions that were able to be compensated or restored in whole or in part are listed, or a note is made that there are no positive results.
On line 23“The condition of a citizen when referred for a medical and social examination (complaints, examination data by the attending physician and doctors of other specialties are indicated) when describing the objective status, each specialist sets out in detail and consistently the patient’s complaints, first of all related to the underlying disease, then others, with exhaustive completeness the data of an objective examination of the patient by specialists is reflected, and the doctor’s specialty is indicated (therapist, surgeon, neurologist, etc.).
If necessary, to record the patient’s condition and the results of examination by specialists, a free-form referral insert can be used, which must be sealed and signed by the chairman of the medical commission and members of the commission.
On line 24 the results of laboratory, radiological, endoscopic, ultrasound, psychological, functional and other types of studies are indicated.
On line 25 The citizen’s body weight in kg, height in meters, and body mass index are indicated. The latter is calculated by the formula:
BMI = Weight (kg)/Height (meters) squared
Pre-obesity 25–29.9
Obesity I degree 30–34.9
Obesity II degree 35–39.9
Obesity III degree 40 or more
A person's height is measured using a stadiometer. Normally, the height of men ranges from 160-180 cm, women 155-170 cm. Body weight is determined using medical scales.
On line 26 an assessment of physical development is given - normal, deviation (underweight, overweight, short stature, high stature) - the necessary is emphasized. Physical development is a set of morphological functional characteristics of an organism that determine its reserve physical strength, endurance and performance.
On line 27“Assessment of psychophysiological endurance: norm, deviation” is underlined as necessary. Psychophysiological endurance is a person’s ability to maintain any activity for a long time without reducing the effectiveness of its implementation, i.e. in a broad sense – performance. Psychophysiological endurance is determined by the degree of physical development, condition functional systems organism, personality traits, temperament, level of motivation to perform activities, and other factors. An assessment of psychophysiological stability is carried out by a psychologist based on an analysis of the dynamics of psychophysiological and physiological indicators in the process of performing psychological tests, sensory, sensorimotor and physical activity, as well as knowledge that imitates different kinds household, professional and other activities. In this case, not just the level of development or state of certain functions is assessed, but, first of all, their characteristics such as stability and the ability to maintain activity at a certain level for a long time.
On line 28“Assessment of emotional stability: norm, deviation” is underlined. Emotional stability is a trait that expresses the preservation of organized behavior in ordinary and stressful situations and is characterized by maturity, excellent adaptation, lack of great tension, anxiety, a tendency to lead, and sociability; emotional instability– extreme nervousness, instability, poor adaptation, tendency to rapid mood swings, feelings of guilt and anxiety, preoccupation, depressive reactions, absentmindedness, instability in stressful situations, impulsiveness, uneven relationships with people, variability of interests, lack of self-confidence, pronounced sensitivity, impressionability, tendency to irritants. Emotional stability is assessed by a psychologist using various projective techniques, questionnaires and scales.
On line 29“Diagnosis upon referral for medical and social examination” in paragraph “a” the code of the underlying disease according to ICD-10 is indicated; in paragraph “b” a detailed diagnosis is indicated, reflecting the nosological form of the disease in accordance with ICD-10, etiology, features of the course, stage, degree functional disorders. When several diseases are combined, the main one is the disease that determines the presence of signs of disability; in paragraph “c” “concomitant diseases” indicate those diseases that are not decisive when assessing limitations in life activity; in paragraph “c”, complications caused by the underlying disease are indicated.
On line 30“Clinical prognosis: favorable, relatively favorable, doubtful (uncertain), unfavorable” is emphasized. Clinical prognosis is a medical assessment of the outcome of the disease, taking into account the nature of the disease and its course, stage, severity of symptoms, degree of dysfunction of the affected organs and systems and the state of their compensation, as well as effectiveness adequate treatment. The prognosis may be: favorable – full recovery or compensation for functions impaired as a result of illness, injury or injury, leading to limitation of life activity; relatively favorable - incomplete recovery with residual manifestations, reduction, stabilization or partial compensation of impaired functions leading to limitation of life activity, with chronic disease– slowing down the progression of the disease, lengthening periods of remission, etc., doubtful – unclear course of the disease, unfavorable – impossibility of stabilizing the health status, stopping the progression pathological process and reducing the degree of dysfunction of the body, leading to limitation of life. In order to predict the degree of restoration of impaired functions, it is possible to use various tests and scales.
On line 31“Rehabilitation potential: high, satisfactory, low” is highlighted as necessary. Rehabilitation potential is a set of preserved physical, psychophysiological, mental abilities and inclinations that allow a person to compensate or eliminate, to one degree or another, limitations in life activity that have developed as a result of an illness or defect. High rehabilitation potential – complete restoration of health, all normal human activities, ability to work and social status. Satisfactory potential – incomplete recovery with persistence of moderately severe dysfunction, performing basic activities with difficulty to a limited extent or with the help of technical aids. Low rehabilitation potential – progressive course of the disease, pronounced violation functions; significant limitation in the performance of most types of activities, expressed by a decrease in working capacity and ability to social integration; need in social support and constant financial assistance. The rehabilitation potential is assessed by the attending physician, who refers the citizen for a medical and social examination.
On line 32“Rehabilitation prognosis: favorable, relatively favorable, doubtful (uncertain), unfavorable” is emphasized. Rehabilitation prognosis is the estimated probability of realizing the rehabilitation potential and the expected level of integration of the disabled person into society. The rehabilitation prognosis is determined not only by the level and content of the rehabilitation potential, but also by the real possibilities of using modern rehabilitation technologies, means and methods for its implementation. The rehabilitation prognosis is assessed as: favorable – if possible full recovery impaired body functions and categories of disability, complete social, including professional integration of the disabled person; relatively favorable - the possibility of partial restoration of impaired body functions and categories of disability, with a decrease in the degree of their restrictions or stabilization, with an expansion of the ability to integrate and the transition from full to partial social support; doubtful (uncertain) – unclear prognosis; unfavorable – the impossibility of restoring or compensating for impaired body functions and categories of disability. The rehabilitation prognosis is assessed by the attending physician, who refers the citizen for a medical and social examination.
On line 33 the purpose of the referral for medical and social examination is indicated (the necessary is underlined): to establish disability, the degree of limitation of the ability to work, the degree of loss of professional ability in percentage, to develop (correct) an individual rehabilitation program for a disabled person (rehabilitation program for a victim of an industrial accident and occupational disease), for another (specify).
On line 34“Recommended measures for medical rehabilitation for the formation or correction of an individual rehabilitation program for a disabled person, a rehabilitation program for a victim of an accident at work and an occupational disease” indicate specific types of rehabilitation therapy (including drug provision in the treatment of the disease that caused disability), reconstructive surgery, technical means of medical rehabilitation, including prosthetics and orthotics, a conclusion on sanatorium treatment with a prescription of the profile, frequency, duration and season of recommended treatment, on the need for special medical care of persons injured as a result of industrial accidents and occupational diseases, on the need for medicines to treat the consequences of accidents at work and occupational diseases, and other types of medical rehabilitation.
The referral is signed by the chairman of the medical commission, members of the commission with a transcript of the signatures and sealed with the seal of the medical institution.
Responsibility for the correct completion of Form No. 088/u-06 “Referral for medical and social examination by an organization providing medical and preventive care” rests with the chairman of the medical commission of the medical and preventive institution, or with the chief physician.
The form must be submitted to the bureau of medical and social examination no later than 1 month from the date of its issue.
Related information.
In line 12 “Conditions and nature of the work performed,” information is recorded from the patient’s words, and, if necessary, requested from the place of work in the form of production characteristics (working hours, shifts; manual, machine-manual, mental work, conveyor: position during work (in percent: sitting, standing, alternating, walking); degree of physical stress: constantly (mild, moderate, severe) and temporarily (mild, moderate, severe); degree of neuropsychic stress: constantly (mild, moderate, severe) and temporarily ( light, moderate, heavy); administrative and economic work (large, medium, small volume), indicate the number of subordinates; the presence of unfavorable working conditions (work in a hot shop, in the cold, increased dust and gas pollution, exposure to chemicals, at height, with vibration).
The procedure for filling out f. No. 088/u-97 “referral for medical and social examination”
Low rehabilitation potential – progressive course of the disease, severe dysfunction; significant limitation in the performance of most types of activities, expressed by a decrease in working capacity and ability for social integration; the need for social support and constant financial assistance. The rehabilitation potential is assessed by the attending physician, who refers the citizen for a medical and social examination. In line 32 “Rehabilitation prognosis: favorable, relatively favorable, doubtful (uncertain), unfavorable” the necessary is emphasized.
Rehabilitation prognosis is the estimated probability of realizing the rehabilitation potential and the expected level of integration of the disabled person into society.
List of documents required for MSEC when registering disability
Referral to ITU in case of temporary disability In the case when a referral for examination arises upon the fact of stable preservation poor condition health, ready to become the basis for recognition of disability, a medical institution can refer to the medical examination when repeating the issuance of sick leave for the same diagnosis. In most cases, a certificate of temporary incapacity for work is issued for a period of up to 10 days; by decision of the medical commission, the certificate is extended to 30 days. In some situations, the medical commission has the right to extend this document for up to 10 months.
In an exceptional situation for a period of up to 12 months, but no more. After 12 months, the patient must be sent for an examination to determine the degree of his ability to work. The commission determines whether it can be further extended sick leave or there will be no final recovery.
Referral to MSE
Clinical prognosis: favorable, relatively favorable, doubtful (uncertain), unfavorable (underline as appropriate). 31. Rehabilitation potential: high, satisfactory, low (underline as appropriate). 32. Rehabilitation prognosis: favorable, relatively favorable, doubtful (uncertain), unfavorable (underline as appropriate).
33. The purpose of referral for a medical and social examination (underline as appropriate): to establish disability, the degree of limitation of the ability to work, the degree of loss of professional ability as a percentage, to develop (correct) an individual rehabilitation program for a disabled person (rehabilitation program for a victim of an accident in production and occupational disease), for other (specify): 34.
Medical and social examination
Line 22 “Results of measures taken for medical rehabilitation in accordance with the individual rehabilitation program for a disabled person” indicates information about measures to restore the patient’s ability to work, specific types of rehabilitation therapy, reconstructive surgery, sanatorium treatment, technical means of rehabilitation, including prosthetics and orthotics, as well as the time frame within which they were provided; body functions that were able to be compensated or restored in whole or in part are listed, or a note is made that there are no positive results.
How to obtain disability and what documents are needed to obtain it
IN " Family doctor» the procedure for obtaining certificate 088/у 06 is clearly planned and requires a minimum of time. You make an appointment at a time convenient for you, come, and the doctor explains to you in detail the procedure. If necessary, you can undergo the necessary examinations at the “Family Doctor” on the same day; if you have the results in your hands, the doctor will enter the data into the certificate form 088/у 06.
Info
After completing the application form, you can go to the MSE (medical and social examination). IN medical center“Family Doctor” - all doctors have extensive experience in diagnosing diseases, and they also know exactly the algorithm for passing a medical and social examination. If you have questions regarding the next steps, the Family Doctor will not only quickly issue you a message for ITU, but will also explain what to do next and where to contact.
The results of the measures taken for medical rehabilitation in accordance with the individual rehabilitation program for a disabled person (to be filled in upon re-referral, specific types of rehabilitation therapy, reconstructive surgery, sanatorium-resort treatment, technical means of medical rehabilitation, including prosthetics and orthotics, are indicated, as well as the terms, in which they were provided; functions of the body are listed that were able to be compensated or restored fully or partially, or a note is made that there are no positive results): 23. The condition of the citizen when referred for a medical and social examination (complaints, examination data by the attending physician and other doctors are indicated specialties): 24.
In line 23 “The condition of a citizen when referred for a medical and social examination (complaints, examination data by the attending physician and doctors of other specialties are indicated), when describing the objective status, each specialist sets out in detail and sequentially the patient’s complaints, first of all related to the underlying disease, then others, The data from an objective examination of the patient by specialists are reflected in exhaustive detail, and the specialty of the doctor (therapist, surgeon, neurologist, etc.) is indicated. If necessary, to record the patient’s condition and the results of examination by specialists, a free-form referral insert can be used, which must be sealed and signed by the chairman of the medical commission and members of the commission.
Disability certificate 088
Attention
Name of service Price Registration of a delivery slip for ITU. Form No. 088/у-06 1500 rub. Making an entry in the mailing list at the ITU. Form No. 088/у-06 900 rub. Certificate 088/у 06 is a referral for a medical and social examination.
It, in turn, is an official procedure in which a person is recognized as disabled and awarded social assistance. Accordingly, without a certificate in Form 088, it is impossible for both an adult and a child to obtain disabled status. Where can I get a referral for a medical and social examination? It can be given in one of three instances: firstly, in medical institution where the patient is being observed, undergoing treatment or rehabilitation. Secondly, in the pension fund department. Thirdly, in the social security authorities. All these options involve queues, a waste of time and effort.
Important
Appendix to the Order of the Ministry of Health and Social Development of the Russian Federation dated January 31, 2007 No. 77 Medical documentation Form No. 088/u-06 Ministry of Health and Social Development of the Russian Federation (name and address of the organization providing treatment and preventive care) DIRECTION TO MEDICAL AND SOCIAL EXAMINATION BY AN ORGANIZATION PROVIDING TREATMENT AND PREVENTIVE CARE Date of issue " " 20 * 1. Last name, first name, patronymic of the citizen sent for a medical and social examination (hereinafter referred to as the citizen): 2. Date of birth: 3. Gender: 4. Last name, name, patronymic of the citizen’s legal representative (filled in if there is a legal representative): 5.
Address of the citizen’s place of residence (if there is no place of residence, the address of residence, actual residence on the territory of the Russian Federation is indicated): 6.
Physical development is a set of morphological functional characteristics of the body that determine its reserve of physical strength, endurance and performance. In line 27 “Evaluation of psychophysiological endurance: norm, deviation” the necessary is emphasized. Psychophysiological endurance is a person’s ability to maintain any activity for a long time without reducing the effectiveness of its implementation, i.e. in a broad sense – performance. Psychophysiological endurance is determined by the degree of physical development, the state of the body's functional systems, personality traits, temperament, level of motivation to perform activities, and other factors.
The Bureau considers complaints about the work of lower authorities and conducts re-examination. Who has the right to send to ITU? Sends for examination: 1) body social protection population; 2) pension authority; 3) medical institutions. If these organizations refuse to give a referral to ITU, then they issue a certificate of this refusal. You can submit the latest document to the bureau yourself.
Documentation required for ITU I. Copy and original of passport or other document that proves identity. II. An application for conducting an ITU, which must be written on the day of submitting the documentation.
III. Form, which is direction. IV. For those who work - information regarding working conditions. V. Also for those working - a copy work book. And for those who do not work - the original work book and its copy. VI.
In order to legally recognize a person as disabled and determine the extent of damage to his health, a medical and social examination is carried out.
Medical and social examination (hereinafter referred to as MSE) is the determination, in the prescribed manner, of the needs of the examined person for social protection measures, including rehabilitation, based on an assessment of the limitations in life activity caused by a persistent disorder of body functions.
MSE involves a comprehensive assessment of the body condition of a disabled person.
The procedure and conditions for recognizing a person as disabled are determined by the Rules for recognizing a person as disabled.
The conditions for recognizing a citizen as disabled are:
a) health impairment with a persistent disorder of body functions caused by diseases, consequences of injuries or defects;
b) limitation of life activity (complete or partial loss by a citizen of the ability or ability to carry out self-service, move independently, navigate, communicate, control one’s behavior, study or engage labor activity);
c) the need for social protection measures, including rehabilitation.
Depending on the degree of disability caused by a persistent disorder of body functions resulting from diseases, consequences of injuries or defects, a citizen recognized as disabled is assigned disability group I, II or III, and a citizen under the age of 18 is assigned the category “disabled child.” "
A referral for a medical and social examination can be obtained:
- in a healthcare institution (polyclinic or other organization where a person receives therapeutic and preventive help);
- in the social protection authority;
- in the body or branch of the Pension Fund of the Russian Federation at the place of residence.
To receive a referral for medical examination, a person must undergo the necessary diagnostic, treatment and rehabilitation measures at a health care institution. Specialists of a medical institution themselves determine a specific list of such examinations and measures if the patient has persistent impairments in body functions caused by diseases, consequences of injuries or defects. Only after full examination, who confirmed the doctors’ fears, the medical institution issues a referral to medical examination.
The social protection body or a branch of the Pension Fund of the Russian Federation can also refer a person who shows signs of disability and who needs social protection for a medical and social examination. But such a person must have medical documents, confirming impairment of body functions caused by diseases, consequences of injuries and defects, for example, certificates or extracts from the medical history.
The form for referral to MSE by an organization providing treatment and preventive care is approved by the Ministry of Health of the Russian Federation. IN this form data on the citizen’s health status are indicated, reflecting the degree of dysfunction of organs and systems, the state of the body’s compensatory capabilities, as well as the results of rehabilitation activities. Today the form is in force (M° 088/у 06, approved by order of the Ministry of Health and Social Development of the Russian Federation dated January 31, 2007 No. 77.
The form of referral to MSE, issued by the body providing pensions or the social protection body, is approved by the Ministry of Labor and Social Protection of the Russian Federation. Today, the form approved by order of the Ministry of Health and Social Development of the Russian Federation dated December 25, 2006 No. 874 is in force.
The referral to the ITU is filled out by the organization sending the person for examination. Organizations providing medical and preventive care, bodies providing pensions, as well as social protection bodies are responsible for the accuracy and completeness of the information specified in the referral to the ITU.
If a medical institution, a body providing pensions, or a social protection body refuses to send a citizen to MSE, he is issued a certificate, on the basis of which the citizen or his legal representative have the right to contact the bureau independently.
MSE is carried out free of charge, at the expense of funds allocated within the framework of the basic program of compulsory health insurance for citizens of the Russian Federation.
The direction indicates the name of the ITU bureau (at the place of residence (at the place of stay, at the location of the pension file of a disabled person who has left the Russian Federation for permanent residence)), where the person should apply.
A citizen referred to ITU must personally contact the ITU office. If the child has not yet reached the age of 14, then his interests are represented by a legal representative (parent, guardian, trustee or adoptive parent).
MSA can be carried out at home if the citizen cannot come to the bureau (main bureau, Federal Bureau) for health reasons, as confirmed by the conclusion of the organization providing medical and preventive care, or in a hospital. where the citizen is undergoing treatment, or in absentia by decision of the relevant bureau.
Anyone applying to an institution for MSA must have a referral for MSA and medical documents confirming the health impairment. The citizen (his legal representative) draws up a written application for conducting ITU(a sample application is usually available from the ITU). The application is submitted to the head of the school. reduction. A referral and medical documents are attached to the application.
If a person only has a certificate of refusal to send him to the ITU, then the bureau’s specialists conduct an examination of the citizen and, based on its results, draw up a program for additional examination of the citizen and rehabilitation measures, after which they consider the question of whether he has a disability.
The day the institution receives a citizen’s application for recognition as a disabled person with the documents attached to it after the necessary examinations is considered the date of disability determination.
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