The medical documentation

  • Documentation military medical
  • Documentation of the medical service of civil defense
  • Documentation forensic
  • Documentation medical system documents of the established form, intended for the data records required for the proper organization of health care, medical institutions and study of the health status of the population.
    Basic requirements for medical records: reliability, medical education, clarity, completeness and timeliness of records. Medical documentation is divided into accounting and reporting.
    The records are to be filled by one person, called documents individual account, such as medical outpatient map, history, history of development of the child and other registration Journal of infectious diseases, the transaction log, etc. are called documents of the group account.
    Basic accounting document in the clinic and the clinic is a medical outpatient map that fits all of applying for Medicaid, the results of examinations, treatment and final diagnosis. Accounting final (adjusted) diagnoses increases the reliability of the data, as the initial diagnoses are not always correct. In the hospital the primary accounting document is history (see), and for a report card eliminated the patient.
    In child health clinics and polyclinics chief accounting document is a history of development of the child.
    In the epidemiological stations main account medical documents: map of sanitary observations of the object (industrial enterprise, the source of water supply, dining room, etc.,) and a map of epidemiological survey of middle of an infectious disease.
    Reporting documents are a generalization of the data contained in the records, and characterize the state of health of the population and activity of a medical institution (see the Statements of health).