A child's medical record is created for each child attending school or kindergarten. The form medical card child is usually standard. Let's look at what the sections of this map consist of.
The child's medical card is used in educational institutions, it is issued for each minor child studying in kindergartens, general education and other schools, and similar organizations.
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The child's medical record 026 U contains detailed data on the degree of moral and physical development of the child, whether he has health problems, and so on. The form of a standard medical record of a student (pupil) also allows you to record information about classifying a minor to a certain disability group by type of health, etc.
The child's medical record is usually filled in by a kindergarten, school health worker - or doctors, nurses or clinic paramedics.
You can download a sample of a child's medical record below.
The medical record is divided into several parts, in which various data about the minor are entered:
According to the regulations, the form of the child's medical record must be filled out by a health worker in accordance with the requirements for its execution.
1.General information about the child.
1.1. Surname, name, patronymic of the child _____________ 1.2. Date of Birth___________
1.3. Gender (M/F) 1.4. House. address (or residential institution address)__________________
1.5. tel. m/live. _____________ 1.6. Serving polyclinic __________________ 1.7. phone ___________________
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1.8. Characteristics of the educational institution* |
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1.8.2. Institutional Society secondary education |
1.8.3 Orphanage |
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The "General Information" section contains all the information about the student (pupil), as well as the medical institution to which he belongs, taking into account the place of residence. The section includes the following information:
The child's medical record 026 U also reports whether the minor has any allergic reaction, indicating the causes of the allergy.
Information about the history of minors is the next section of the medical record 026 U. It contains general data and characteristics of the family of a school student or kindergarten pupil. In addition, it contains information about the living conditions of the child, describes the diseases that he suffered. Externally, the section looks like this:
The most significant points in this section of the child's medical record:
The health worker of the school or boarding school enters information about all this based on the data of a regular outpatient medical card, and based on the results of a personal conversation with his parents and information received from teachers of the school or boarding school.
The next section of the child's medical record directly relates to children who need to be monitored by a doctor in a clinic in their place of residence.
Externally, the section of the child's medical record form looks like this:
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Control of specialist visits |
date of removal, reason |
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The purpose of completing this section is to control the implementation of various dispensary procedures. The health worker of the school or boarding school moves them to the child's card from the medical card of the polyclinic. It is extremely important to fill in all the columns of this block with data. And if a student (pupil) is removed from dispensary medical observation, the date and reasons for deregistration of the student (pupil) must be entered in this section of the child’s medical record form.
The fourth section includes data on the implementation of mandatory medical and diagnostic measures, for example, on the dates, terms and results of deworming or on the sanitation of the oral cavity of underage students (pupils).
Externally, the section looks like this:
Mandatory therapeutic and preventive measures
4.1 Deworming
4.2. Sanitation of the oral cavity
In the Russian Federation, in each institution, when observing a school student or kindergarten pupil, medical specialists are guided by the legislative acts of the Ministry of Health of the Russian Federation when working:
These legislative acts regulate the frequency of medical examinations and other compulsory medical measures for underage students and pupils. In the described section of the child's medical record form, notes are recorded on the passage of these procedures with the addition of specific dates and types of events.
This section includes data from doctors about what and when vaccinations were given to a minor who was not observed by health workers. The section contains dates and dates of immunization activities, regardless of the cases for which vaccinations were made.
Section appearance:
Immunoprophylactic measures
5.1. Examination of a school student or kindergarten pupil before preventive and other vaccinations
In column (5.1.), the health worker indicates what diagnosis the student (pupil) had at the time of the vaccination. If the presence of this disease clearly conflicts with the possibility of immunization, or is a direct contraindication for it, the medical record of a school student or kindergarten pupil indicates the date until which vaccinations are postponed. Also, the name, dose and method of administration of the immunoprophylactic drug, as well as the series of vaccine used, are reported in the child's medical record. Subsequently, according to these data, among other things, the reaction of a school student or a kindergarten pupil to vaccination is monitored. The results of the observation are also then entered into the children's medical record.
Data on the passage of scheduled preventive medical examinations by a school student or kindergarten pupil
The sixth section is differentiated into 10 columns, which correlate with the periods of examinations of students (pupils) in different periods of their lives:
Data of planned medical examinations (6.1 - before entering a nursery-kindergarten, kindergarten, 6.2 - 1 year before a comprehensive school, 6.3 - before a secondary school)
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Parameters, specialists |
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Date of examination |
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Age (years, months) |
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body length |
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Body mass |
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Pediatrician (including heart rate for 1 min. BP - 3 times) |
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Ophthalmologist |
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Otolaryngologist |
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Dermatologist |
As part of the mandatory medical examinations, health workers enter in the columns of this section of the child's medical record the results of external and laboratory examinations of the student (pupil):
Based on the results of the medical examination, the examined student (pupil) is assigned to the desired health group. Then follows the conclusion of the conclusion about his state of health - both physical and mental.
In the section of the child's medical record form, dedicated to the results of medical examinations of the student (pupil) and doctor's consultations, information is entered that is based on up-to-date data - the results of medical examinations and conclusions after observing children.
In the column with the name "Professions" they enter those options for professions that the student (pupil) is going to master and subsequently use, the reference point is his words. The “Recommendations” column contains the conclusion of the district pediatrician, based on an assessment of the state and degree of health of the minor, the problems that the student (pupil) has, the presence of diseases or any deviations, if any.
Forms of certificates can be very diverse and depend on which particular team the person is to be in. In our country, a whole system of documents has been developed for these purposes.
In this article, we will study the issue of registration and obtaining a certificate, without which the child cannot be admitted to kindergarten. Attending preschool educational institutions is an important step in the life of both children and their parents. Therefore, you need to know exactly what is needed in order for the baby to start going to the garden. We will talk about the child's medical record form 026 / y, since parents are interested in what information it should contain and how it is issued.
The child enters kindergarten and school on the basis of the Order of the Ministry of Health of the Russian Federation. It is recommended to collect medical documents 1-2 months before the date of the first visit to a general education institution.
Consider the medical documents required for placement in a school or kindergarten. These include:
Card of preventive vaccinations F-63;
Medical card F-026u;
Vaccination certificate (blue book);
Information about the epidemiological environment.
Form 026 / y is required for the child to be accepted into the team kindergarten or general education institution. Carrying out the examination provided for obtaining the card is important point not only to avoid the outbreak of epidemics in the group of preschoolers, but also to control the health of children. That is, in fact, it is a preventive measure. It must be remembered that a timely detected pathology gives a high chance of its complete elimination without consequences. What else does a child's medical card give?
In addition, if during the examination a child’s health problem is diagnosed, he can be sent to a specialized preschool institution, and parents will receive special recommendations about further action. If vision problems are found, then parents are advised to consider the option of a special kindergarten for children with similar pathologies. Such recommendations are not something terrible, on the contrary, they are aimed at ensuring that the child is provided with specialized assistance in restoring vision. Such kindergartens direct their activities to improve the health of children with visual pathologies.
If a student has pathologies that do not allow high-intensity physical activity, the pediatrician can issue a special permit for not attending physical education classes at school. It can be either temporary, until the problem is fixed, or permanent.
The main question for all parents is which specific specialists need to be visited to obtain a certificate. The child's medical record involves consultations with a wide range of doctors. For its registration, first of all, you should visit a pediatrician. He will issue the necessary referrals to specialists, including for tests.
As a standard, the list of required specialists includes:
If the child suffers from any diseases in a chronic form, then at the discretion of the pediatrician, referrals to other narrow specialists, such as a speech therapist, gynecologist, psychologist, endocrinologist or andrologist, may be issued. The Ministry of Health recommends going to a gynecologist for girls and an andrologist for boys from the age of 14. This is necessary even without indications, for the prevention of sexually transmitted diseases and pathologies in the reproductive system. It should be borne in mind that these specialists are not included in the mandatory visit list, and an examination can only be carried out in the presence of the child's parent.
In addition to visiting and consulting narrow specialists, in order to obtain a child's medical card, it is necessary to pass a series of tests. As a rule, these are standard studies:
As a rule, the results of the research are provided a few days after the date of delivery. It depends on the workload of the outpatient laboratory. After receiving all the test sheets, a second visit to the pediatrician is required to issue a card. After that, it must be signed by the head physician of the clinic. The document is provided to the kindergarten at the request of the administration of the preschool institution. An example of a child's medical record is provided below.
It is considered optimal to give it a month before the expected start of the child's visit to kindergarten. A certificate to school is given before September 1, otherwise the child may not be allowed to attend classes. Thus, it is necessary to take into account the time for issuing a card in order to provide it in a timely manner at the place of demand.
The child's medical record 026 / y is signed by the head physician of the medical institution only if all the tests have been passed.
In order not to have to repeat the analyzes due to the unreliability of the data, it is important to follow certain recommendations when preparing for them. These standard tips include:
When the passage of the commission for issuing a child's medical card for kindergarten form 026 / y takes place at the clinic at the place of residence, only the child's policy is required. All necessary information specialists will be able to find it in the child's development card stored in the clinic, including birth data and a vaccination card. If the choice fell on private clinic, then you will need to provide a package of documents, including:
The form of the child's medical record for the garden is filled out by a nurse or pediatrician. The following data is indicated on the front side of the document:
Each narrow specialist fills out his own column in the medical record after examination and consultation. When all indicators are normal, a “healthy” mark is placed in a special column. If there are pathologies, the specialist enters data about them into the map and makes a decision on whether the child can attend the kindergarten on general terms.
How much does it cost to issue a child's medical card for kindergarten?
A medical commission is carried out free of charge in the children's clinic at the place of residence. This process is quite lengthy, sometimes it takes more than a week, which is due to the discrepancy between the schedule of district specialists. It also takes quite a lot of time in state clinics to conduct tests. This is due to the poor equipment of laboratories in the clinic and their abnormal workload.
There are cases when schoolchildren are offered the option of passing a medical commission directly to educational institution. It's also free and obviously convenient for both the child and the parents.
It is possible to issue a child's medical card on a private basis in a non-state clinic. The main advantage of this option is speed. Subject to prior appointment with specialists, required document can be received the next day after applying. With this option, it is possible to pass specialists even within one hour. However, you will have to pay a lot for such a high speed of service, since the cost will include consultations of specialists and laboratory tests.
The average cost of a medical examination is from three thousand rubles. It all depends on the chosen clinic. Private medical institutions offer a comprehensive examination for a certain amount. However, before using such offers, carefully study which specific specialists and examinations are included in the price so that you do not have to pay extra for the necessary consultation in the future. The purpose of passing a medical examination is not only and not so much in the design of a card, but also in the prevention of diseases and pathologies.
We have reviewed the child's medical record form 026/y.
OKUD form code _______________
Institution code according to OKPO _________
Ministry of Health Medical records
Form No. 003 U
The name of the institution is approved by the Ministry of Health of the USSR
___________________________№ 1030
Date and time of receipt
Date and time of checkout _____________________________
Department ____________________ ward No. _______
Transferred to the department _______________________________________________
Bed-days spent _______________________________________________
Types of transportation: on a wheelchair, on a chair, can walk (underline)
Blood type ____________ Rh affiliation _____________________
Side effects of drugs (intolerance)
1. Surname, name, patronymic: _____________________________________________
2. Gender: ____________
3. Age: ____ (full years, for children: up to 1 year - months, up to 1 month - days)
4. permanent place residence: city, village(emphasize)
5. Place of work, profession or position _______________________________________________
place of study for students; for children - the name of the children's institution, school; for disabled people, type and group of disability, JOB - yes, no (underline)
6. Who referred the patient: __________________________________
7. Delivered to the hospital for emergency indications: yes, no - ________ hours after the onset of the disease, injuries received, hospitalized in a planned manner (underline)
8. Diagnosis of the referring institution: _____________________________________________
9. Diagnosis at admission _________________________
10. Clinical diagnosis ______________________ Date of establishment __________________
11. Final clinical diagnosis
a) main ________________________________________________________________
b) complication of the main ___________________________________________________
c) concomitant ________________________________________________________________
Purpose: to ensure continuity in the actions of health workers.
Note: by the time the duty is handed over, all manipulations assigned to patients must be performed by the nurse handing over the shift.
Action algorithm
I. The nurses receiving and handing over the duty, together with the head nurse of the department, must:
1) make a round of all the wards with a report on patients in serious condition;
2) inspect the sanitary condition of the ward, ask the opinion of patients about the past duty (if there are any complaints or suggestions);
3) accept medical documentation:
a) a journal of medical appointments;
b) log of acceptance and delivery of duty;
c) registers of medicines of list A and B, together with the keys to the safe in which they are stored;
4) transfer medical instruments: thermometers, blood pressure monitors, syringes, etc.;
5) retake medicines that are at the post;
6) both nurses are present at the medical conference; handing over a shift nurse reports on the dynamics of the state of patients, on the past duty, reports a summary of the movement of patients per day;
7) the nurse on duty fills out in the morning the “Sheet for the movement of patients and the hospital bed fund” and the “Portion requirement” in two copies - for the catering department and the distributor
DEVELOPING A PORTION REQUIREMENT
Goal: Patients comply with the diet prescribed by the doctor.
Portion requirement forms f No. 1-84.
for the nutrition of patients in the therapeutic department at ________________________________
(date, day, month, year)
Information about the presence of patients as of 10:00
(day month Year)
- Select numbers of therapeutic diets for each patient from the prescription sheets.
- Enter them in the general list of patients at the post.
- Submit to the head nurse by 9 o'clock the number of patients excluding those who are discharged today, as well as the number of meals for each treatment table and additional meals prescribed.
Examples of frequent violations that will be revealed during checks for the correct filling of outpatient cards. An example of filling out a medical card of an outpatient.
Outpatient card, last changes forms, the order of registration and filling in information, see the article.
In the material we will answer the question: what are the criteria for the quality of filling out the medical card of an outpatient patient now.
We will also give examples of frequent violations that will be revealed during checks for the correct filling of patient cards.
From the article you will learn
The outpatient card is the main accounting medical document a medical institution providing assistance to citizens in a polyclinic.
note
The Ministry of Health continues to change the procedure for advanced training of medical and pharmaceutical workers. The main changes will come into effect on January 1, 2020. Which doctors need to urgently undergo training and what the chief medical officer should do - in the magazine "Deputy Chief Physician".
The procedure for maintaining medical documentation is defined in the order of the Ministry of Health of the Russian Federation No. 384n of December 15, 2014.
Particularly important are Annexes 1 and 2, which approved the registration form No. 025 / y “Medical record of a patient receiving medical care on an outpatient basis” and the procedure for its management.
New form of medical card outpatient is more detailed and requires the collection of additional data on the patient's health status.
Filling out the outpatient card of the patient is carried out for all persons who appeared at the initial appointment with a specialist of a medical institution.
All attending and consulting physicians of the patient make entries in it.
Medical institutions of phthisiatric, oncological, dermatological, dental, psychiatric and narcological profiles have their own separate accounting forms, therefore, an outpatient card does not start on them.
The registration of the medical card takes place at the reception desk of the polyclinic. It is started in the registry of the institution for all patients who first applied for help.
The title page of the outpatient medical record includes:
All outpatient cards are stored in the registry of the polyclinic and are grouped according to the territorial-district principle.
Cards of citizens who can receive certain social services are marked with the letter "L" next to the card number.
The medical record records the nature of the course of the patient's illness, as well as all the performed diagnostic and treatment procedures in a certain sequence.
Also, each subsequent visit of the patient to the clinic is entered into it.
All entries in the map are in Russian. They must be accurate, corrections are not allowed.
Note
Soon it will be necessary to apply clinical recommendations along with the orders and standards of medical care. What is required from the chief medical officer today and will be required tomorrow, read in the magazine "Deputy Chief Physician".
If the doctor needs to correct something, he must certify the correction with his signature. It is possible to record prescribed medicines in Latin.
Items 2-6 outpatient medical record filled in on the basis of data taken from a citizen's passport.
Paragraph 12, which indicates the diagnosis-basis for establishing dispensary observation (according to ICD-10), causes a lot of difficulties and questions for health workers.
Patients who visit several doctors for the same disease require special attention (for example, about diabetes mellitus with a general practitioner and an endocrinologist).
Each of them is written once by the doctor who first registered the patient. If the patient is observed in the clinic due to several unrelated pathologies in one or more narrow specialists, then the name of each of them is indicated in paragraph 12.
According to the patient, such items of the outpatient card are filled in as:
Paragraphs 24-25 determine the order of registration of medical specialists - the corresponding lines are filled in at the first examination of the patient and during his dynamic observation.
Professional records must contain the following information:
In addition, the patient's voluntary informed consent to the intervention or refusal of it is reflected in the initial appointment in the patient's outpatient card.
Item 26 of form No. 025 / y - discharge summary. It is filled out when the patient is referred for CEC or with a period of disability for more than 14 days, signed by the attending physician and includes information about the patient, his condition in dynamics over a certain period of time based on the results of the examination and therapy.
☆ Read the rules for compiling a discharge summary according to JCI standards in the magazine "Deputy Chief Physician".
However, it is worth noting that in the Procedure for filling out an outpatient medical record, there are no explanations regarding the cases in which it is necessary to fill out a discharge summary.
Two options are possible here - either when referring to a KEK, or when registering temporary disability for more than 14 days. This issue should be resolved at the level of the chief physician of a medical organization.
Paragraph 27 of the outpatient medical card contains information about the consultations of the head. department. However, here the question arises - with what frequency the head. should the department conduct routine consultations with outpatient patients?
There is no answer to it in the orders and resolutions of the Ministry of Health, therefore this issue, like the previous one, is regulated by the internal documents of the institution.
Paragraph 29 "Conclusion of the medical commission" requires special attention - it reminds health workers that there are a number of issues related to the provision of medical care, the consideration of which is within the competence of the medical commission. In addition, he determines the form of recording her decision in the medical documentation.
Item 35 of the patient's outpatient card - epicrisis.
It is issued in the following cases:
In the first case, the epicrisis is issued personally to the patient or sent to the clinic where he will be observed. In the second case, this document is post-mortem in nature, all illnesses, injuries, interventions, the final post-mortem diagnosis (divided into sections) are entered into it.
In addition, the series, number and date of issue of the medical death certificate with a description of all the causes of death indicated in it are indicated. After the death of the patient, the outpatient card is removed from the registry and transferred to the archive, where it is stored for 25 years.
The Ministry of Health plans to increase the number of patients with electronic medical records. Medical organizations will have to gradually switch to legally valid electronic document management and send information on each case of medical care to Personal Area patient "My Health" at EPGU.
Download a proven algorithm for implementing electronic document management, a non-disclosure obligation and a personal data processing policy in the magazine article "Deputy Chief Physician".
The patient's individual medical record meets the quality criteria if all sections are filled in and the patient agrees to treatment or refuses it.
The criteria for evaluating the quality of filling include:
The information that should be included in the outpatient medical record is presented in the table below:
The main violations committed when filling out an outpatient medical card include:
Form 025/y 04 was put into circulation in 2004. The form was developed by the Ministry of Health. Approving document - Order number 255. The outpatient medical record form 025 / y 04 is used by institutions providing outpatient care (without providing a bed).
Form 025 / y 04 is filled out during the initial visit to the institution by the patient or when leaving the house to provide medical services. One copy of the card is created for one patient in one institution. If the patient is observed by several specialists, then they use the same document to keep records. duplication primary documentation would inevitably confuse the history of the disease and complicate treatment.
Outpatient card form 025 / y 04 can be used by any medical outpatient organization, regardless of location or specialization. The form is used by FAPs and health centers. The location of the form is the clinic registry. This is where you fill in the information on the title page.
Medical card form 025 / y 04 is a landscape-type card that includes a title page and inner pages for entering information. When printing, the form is made in full accordance with the form. Changes to an existing document are not allowed.
Card form 025/y 04 contains important personal information about the patient. The document includes not only basic passport data, but also phone numbers that allow you to contact the patient, information about the place of work. Number must be entered insurance policy and SNILS. For people who have any benefits, you must also enter the benefit code. If there is a disability, the appropriate column is filled in. Information about the change of address and place of work is also entered into the form 025 / y 04.
For a medical institution, a medical card (form 025 / y 04) is the main document of a citizen receiving outpatient services. The form contains up-to-date information about the main diagnosed diseases of the patient. Information about the presence of already existing diseases subject to dispensary observation is entered in the appropriate columns. This is an important source for the attending physician.
Information about such parameters of the patient as blood type, Rh factor and drug intolerance is also important. These data play a major role in the provision of certain types of emergency care, surgical interventions.
The map contains loose sheets that describe the dynamics of the course of diseases. All visits or home services are recorded. The form also records cases of issuing disability certificates. During treatment, the patient may require hospitalization in a hospital at the clinic. In this case, form 025 / y 04 is transferred to the hospital for the duration of treatment and is added to the main medical record of the patient in the hospital.
You can buy a medical card of a patient form 025 y 04 in Moscow at the City Blank printing house. We can produce an outpatient card form 025/u 04 in a single copy or print a batch right size. A certain number of molds may be in stock. Check availability with managers.
You can pick up a medical card in person when visiting our offices. It is possible to order courier delivery to the door. We also cooperate with the largest carrier companies, and we can send the purchase to any region of Russia. Postal delivery to the desired location is possible.
