Characteristics of the organization of work of the therapeutic area in the clinic. Job responsibilities of a local general practitioner

· carrying out preventive measures to prevent and reduce morbidity, identifying early and latent forms of diseases, socially significant diseases and risk factors

· carrying out medical examination of the population

· dispensary monitoring of the health status of persons suffering from chronic diseases

· Conducting all types of medical examinations

· organization of sanitary and anti-epidemic measures

· organization of vaccination events

Medical examinations – a set of medical interventions aimed at identifying pathological conditions, diseases and risk factors for their development.

Types of medical examinations:

· Preventative medical examination carried out for the purpose of early (timely) detection of pathological conditions, diseases and risk factors for their development, non-medical consumption narcotic drugs and psychotropic substances, as well as for the purpose of forming health status groups and developing recommendations for patients

· Preliminary medical examination carried out upon entry to work or study in order to determine the compliance of the employee’s health status with the work assigned to him, and the student’s compliance with training requirements

· Periodic medical examination carried out at established intervals for the purpose of dynamic monitoring of the health status of workers, students, timely detection of initial forms of occupational diseases, early signs of exposure to harmful and (or) hazardous production factors of the working environment, labor, educational process on the health status of workers and students, in order to form risk groups for the development of occupational diseases, identify medical contraindications to the implementation of certain types of work, and continuation of studies;

· In-depth medical examinations periodic medical examinations with an expanded list of medical specialists and examination methods participating in them. Conducted in relation to individual categories of citizens in cases provided for by law Russian Federation.

· Pre-shift, pre-trip medical examinations

· Post-shift, pre-trip medical examinations

Preventative work estimated:

· complete coverage of honey. inspections (the ratio of the number of those examined to the number of the population subject to inspection, multiplied by 100);

· percentage of the population examined to identify the disease (the ratio of the number of examined people to the population);

· frequency of detected diseases (the ratio of the number of detected diseases to the number of examined ones);

· clinical examination indicators (completeness of coverage, timeliness of registration at the clinical examination, specific weight of those newly taken under observation, average number of those undergoing medical examination at one site, outcomes and effectiveness of clinical examination).

Prevention– disease prevention, an integral part of medicine Kinds:

· primary – a set of measures aimed at preventing the development of acute diseases.

· secondary – a set of measures aimed at preventing the development of chronic diseases.

· tertiary – a set of measures aimed at preventing the development of disability in society and preventing deaths.

The most important integral part of all preventive measures is the formation of medical and social activity among the population and attitudes towards a healthy lifestyle

Healthy lifestyle promotion: methods of oral, printed, visual and combined propaganda.

The method of oral propaganda is the most effective. It includes: lectures, conversations, discussions, conferences, club classes, quizzes.

The clinic operates according to territorial-area principle. When forming therapeutic areas, their length and distance from the clinic are taken into account; based on this, the population size in the area may fluctuate somewhat ( standard 1300 people)

Types of plots:

a) territorial - therapeutic, obstetric, pediatric

b) workshop

c) rural medical center - has an examination radius of up to 10 km, includes a first aid station, a medical outpatient clinic, and a local hospital.

d) assigned

Organization of the work of a local therapist.

Appointments at the clinic and home visits by a therapist are carried out in accordance with a schedule that should ensure availability medical care, including on holidays and weekends. The schedule includes hours for outpatient visits, home care, preventive and other work.

The local physician is, as a rule, the first doctor to whom the population of the district turns for medical help. He is obliged to provide ( content of the work of a local therapist):

Timely qualified therapeutic assistance in the clinic and at home;

Timely hospitalization of therapeutic patients with mandatory examination during planned hospitalization;

IN necessary cases consultation of patients with the head of the department and doctors of other specialties;

Examination of temporary disability;

Organization and implementation of a set of medical examination measures;

Issuing conclusions to those undergoing a medical examination;

Organization and implementation of preventive vaccinations and deworming of the population;

Emergency medical care for patients regardless of their place of residence.

50. Office of infectious diseases of the clinic. Sections and methods of work of a doctor in the office of infectious diseases.

Main tasks (sections and methods of work) of the office infectious diseases:

Ensuring timely and early detection and treatment of infectious patients;

Study and analysis of the dynamics of infectious morbidity;

Dispensary observation of convalescents and bacteria carriers;

Promoting knowledge on the prevention of infectious diseases.

The procedure for obtaining and storing vaccination preparations. Upon receipt of applications, the Central State Examination Center draws up a consolidated updated plan for preventive vaccinations for a given year for all medical institutions in the district. The clinic receives bacterial medications from the Center for State Examination in accordance with the submitted application. Vaccines must be strictly registered and stored under certain conditions, regulated by the instructions attached to each drug.

Basic documentation of the infectious diseases office:

a) accounting:

Control card of dispensary patient 030/u;

Emergency notification of an infectious disease, acute occupational poisoning, unusual reaction to vaccination 058/u;

Journal of infectious diseases 060/у;

Register of preventive vaccinations 064/у.

b) reporting:

Report on preventive vaccinations f. No. 5 – submitted to the Center for State Examination;

Report on the movement of vaccination preparations f. No. 20 – submitted to the Center for State Examination;

Report on the movement of infectious diseases;

A report on the examination of patients for diphtheria is submitted to the Center for State Examination.

51. Preventive work of the clinic. Organization preventive examinations. Dispensary method in the work of the clinic, its elements. Control card of dispensary observation, information reflected in it.

A distinctive feature of medical care provided in clinics is the organic combination of therapeutic and preventive work in the activities of all doctors of this institution.

3 main areas of preventive medicine:

a) withhealth education work- when communicating with each patient, the principles of a healthy lifestyle and regime for a specific disease, the basics of rational and therapeutic nutrition, the harm of smoking and alcohol abuse and other sanitary and hygienic aspects should be explained to him; The doctor also gives lectures in clinics and at enterprises, issues health bulletins and other information materials, etc.

b) grafting work- carried out under the guidance of immunologists by infectious disease specialists and local therapists at the clinic (in recent years, there has been an urgent need for universal vaccination of the adult population against diphtheria)

V) clinical examination (dispensary method) is a method of active dynamic monitoring of the health status of the population, aimed at strengthening health and increasing working capacity, ensuring proper physical development and preventing diseases through a set of therapeutic, health-improving and preventive measures. The dispensary method of operation of health care facilities most fully expresses the preventive orientation of health care.

Contingents subject to medical examination, include both healthy and sick people.

Group 1 (healthy) includes:

Persons who, due to their physiological characteristics, require systematic monitoring of their health (children, adolescents, pregnant women);

Persons exposed to adverse factors in the working environment;

Decreed contingents (food workers, utility workers, public and passenger transport workers, personnel of children's and medical institutions, etc.);

Special contingents (persons affected by the Chernobyl disaster);

Disabled people and participants of the Great Patriotic War and equivalent contingents.

Clinical examination healthy aims to preserve health and ability to work, identify risk factors for the development of diseases and their elimination, prevent the occurrence of diseases and injuries through the implementation of preventive and health-improving measures.

Group 2 (patients) includes:

Patients with chronic diseases;

Convalescents after some acute diseases;

Patients with congenital (genetic) diseases and developmental defects.

Clinical examination sick provides for early detection of diseases and elimination of the causes contributing to their occurrence; prevention of exacerbations, relapses, complications; preservation of working capacity and active longevity; reducing morbidity, disability and mortality through the provision of comprehensive qualified medical care, health and rehabilitation measures.

Medical examination tasks:

identifying people with risk factors and patients in the early stages of diseases by conducting annual preventive examinations of mandatory contingents and, if possible, other groups of the population;

active monitoring and rehabilitation of patients and persons with risk factors;

examination, treatment and rehabilitation of patients according to their appeal, dynamic monitoring of them;

creation of automated information systems and data banks for dispensary registration of the population.

Stages of medical examination:

1st stage. Registration, examination of the population and selection of contingents for registration at the dispensary.

a) registration of the population by area by conducting a census by a paramedical worker

b) survey of the population to assess health status, identify risk factors, and early detection of patients.

Identification of patients is carried out during preventive examinations of the population, when patients seek medical care in health care facilities and at home, during active calls to the doctor, as well as during special examinations regarding contacts with an infectious patient.

Distinguish 3 types of preventive examinations.

1) preliminary- carried out to persons entering work or study in order to determine the suitability (suitability) of workers and employees for their chosen job and identify diseases that may be contraindications for work in this profession.

2) periodic- carried out to persons in a planned manner at a specified time for certain groups of the population and with the current appeal for medical help to medical institutions.

To contingents subject to mandatory periodic inspections, relate:

Workers of industrial enterprises with harmful and dangerous working conditions;

Workers of leading professions in agricultural production;

Decreed contingents;

Children and teenagers, young men of pre-conscription age;

Students of vocational schools, technical schools, university students;

Pregnant women;

Disabled people and participants of the Great Patriotic War and equivalent contingents;

Persons affected by the Chernobyl disaster.

For the rest of the population, the doctor must use every patient visit to a medical facility to conduct a preventive examination.

3) target- carried out for early detection of patients with certain diseases (tuberculosis, malignant neoplasms, etc.)

The main forms of preventive examinations are

A. individual- are carried out:

According to the population’s appeal to health care facilities (for a certificate, for the purpose of obtaining a sanatorium-resort card, in connection with a disease);

When actively calling persons served by the clinic for a medical examination at the clinic;

When doctors visit patients with chronic diseases at home;

Among persons undergoing treatment in a hospital;

When examining persons who were in contact with an infectious patient.

This is the main form of medical examinations of the unorganized population.

b. massive- are carried out, as a rule, among organized groups of the population: children of preschool and school institutions, young men of pre-conscription age, students of secondary specialized institutions and university students, workers and employees of enterprises and institutions. Mass preventive examinations, as a rule, are comprehensive and combine periodic and targeted ones.

Inspections of organized teams are carried out on the basis of agreed schedules and are regulated by relevant orders of the Ministry of Health.

Data from medical examinations and the results of examinations performed are recorded to medical records(“Medical record of an outpatient”, “Individual record of a pregnant and postpartum woman”, “History of the child’s development”).

Based on the results of the examination, a conclusion is given on the state of health and a determination is made. observation group:

a) group “healthy” (D1)– these are persons who do not complain and whose history and examination do not reveal any deviations in their state of health.

b) group “practically healthy” (D2) – persons with a history of chronic diseases without exacerbations for several years, persons with borderline conditions and risk factors, often and long-term illnesses, convalescents after acute diseases.

c) group “chronic patients” (D3):

Persons with a compensated course of the disease with rare exacerbations, short-term loss of ability to work, which does not interfere with normal work activities;

Patients with a subcompensated course of the disease, who experience frequent annual exacerbations, prolonged loss of ability to work and its limitation;

Patients with a decompensated course of the disease, having persistent pathological changes, irreversible processes leading to permanent loss of ability to work and disability.

When a disease is detected in the person being examined, the doctor fills out a statistical coupon (form. 025/2-u); makes notes about the state of health in the medical record of an outpatient (f.025/u). Persons classified in the third health group are registered at the dispensary by a local doctor or medical specialist. When taking a patient to the dispensary register, a control card of dispensary observation (f.030/u), which is kept by the doctor performing dispensary observation of the patient. The control chart indicates: doctor's surname, date of registration and deregistration, reason for deregistration, disease for which he was taken under dispensary observation, number of the patient's outpatient card, his surname, first name, patronymic, age, gender, address, place of work, doctor's attendance, records of changes in the initial diagnosis, concomitant diseases, a set of treatment and preventive measures.

Conducting a preventive examination without subsequent therapeutic, health-improving and preventive measures does not make sense. Therefore, for each dispensary patient, a dispensary observation plan is drawn up, which is noted in the dispensary observation control chart and in the outpatient medical record.

2nd stage. Dynamic monitoring of the health status of those being examined and carrying out preventive and therapeutic measures.

Dynamic observation of the person being examined is carried out differentiated according to health groups:

a) monitoring of healthy people (group 1) - carried out in the form of periodic medical examinations. Mandatory populations undergo annual examinations according to the plan within the established time limits. In relation to other contingents, the doctor must make the most of any patient’s appearance at the medical facility. In relation to this group of the population, health-improving and preventive actions aimed at preventing diseases, promoting health, improving working and living conditions, as well as promoting a healthy lifestyle.

b) monitoring of persons classified in group 2 (practically healthy) is aimed at eliminating or reducing risk factors for the development of diseases, correcting hygienic behavior, increasing the compensatory capabilities and resistance of the body. Monitoring patients who have suffered acute diseases is aimed at preventing the development of complications and chronicity of the process. The frequency and duration of observation depend on the nosological form, the nature of the process, and possible consequences (after acute tonsillitis, the duration of medical examination is 1 month). Patients with acute diseases that have a high risk of chronicity and the development of severe complications are subject to dispensary observation by a general practitioner: acute pneumonia, acute tonsillitis, infectious hepatitis, acute glomerulonephritis and others.

c) observation of persons classified in group 3 (chronic patients) is carried out on the basis of a plan of treatment and health measures, which provides for the number of clinical visits to the doctor; consultations with specialist doctors; diagnostic studies; drug and anti-relapse treatment; physiotherapeutic procedures; physical therapy; dietary food, Spa treatment; sanitization of foci of infection; planned hospitalization; rehabilitation measures; rational employment, etc.

Dispensary group of patients with chronic diseases, subject to dispensary observation by general practitioners are patients with the following diseases: chronic bronchitis, bronchial asthma, bronchiectasis, lung abscess, hypertension, NCD, ischemic heart disease, peptic ulcer stomach and duodenum, chronic gastritis with secretory insufficiency, chronic hepatitis, cirrhosis of the liver, chronic cholecystitis and cholelithiasis, chronic colitis and enterocolitis, ulcerative colitis, urolithiasis, chronic glomerulonephritis, chronic pyelonephritis, osteoarthritis, rheumatism, rheumatoid arthritis, often and long-term illness. If there are doctors of narrow specialties in the clinic, specialized patients, depending on age and stage of compensation, can be under dispensary observation from these specialists.

A group of dispensary patients subject to dispensary observation by a surgeon, are patients with phlebitis and thrombophlebitis, varicose veins of the lower extremities, post-resection syndromes, chronic osteomyelitis, endarteritis, trophic ulcers etc.

During dynamic observation, planned activities throughout the year are carried out, adjusted, and supplemented. At the end of the year, a staged epicrisis is filled out for each person undergoing medical examination, which reflects the following points: the initial condition of the patient; carried out medical and recreational activities; dynamics of the disease; final assessment of health status (improvement, deterioration, no change). The epicrisis is reviewed and signed by the head of the department. For convenience, many health care facilities use special forms such as “dispensary observation plan-epicrisis”, which are pasted into the medical record and can significantly reduce the time spent on documentation.

3rd stage. Annual analysis the state of dispensary work in health care facilities, assessing its effectiveness and developing measures to improve it (see question 51).

Carrying out clinical examination of the population is regulated by the following documents:

Order of the Ministry of Health of the Republic of Belarus No. 10 dated January 10, 1994 “On mandatory medical examinations of workers employed in hazardous and hazardous conditions labor" (Appendix 1).

Order of the Ministry of Health of the Republic of Belarus No. 159 of October 20, 1995 “On the development of integrated prevention programs and improvement of the clinical examination method” (Appendix 2).

Order of the Ministry of Health of the Republic of Belarus No. 159 dated June 27, 1997 “On the implementation of the integrated prevention program non-communicable diseases(CINDY) in the Republic of Belarus."

The implementation of this principle is facilitated by the fact that the professional activities of medical workers in our country take place under the conditions of a unified state healthcare system. This ensures planning, deep scientific and social validity of therapeutic and health measures, and comprehensive assistance and support.

Because the internal illnesses occupy first place in the structure of population morbidity, the leading role in practical healthcare belongs to the local general practitioner. More than 50% of all initial visits to the clinic are made by a general practitioner. However, only 20% of those who sought medical help require subsequent hospitalization. The remaining 80% are examined and treated in a clinic.

The principle of locality

The organization of outpatient therapeutic care is based on the local-territorial principle. The territory served by each clinic is divided into sections, each of which is assigned to a specific general practitioner. According to established standards, no more than 3,000 adults should live in one medical area. In 1962, the national average for a therapeutic medical area was 3078.5 residents. The precinct principle has a number of very important advantages before other possible options for organizing outpatient care. With average numbers of visits within 2 years, the clinic is visited by almost 90% of the entire population of the district, and after 3 years of work, the doctor becomes closely acquainted with almost every resident of his district. This gives the local therapist the opportunity to know well the health status of the members of each family, the peculiarities of everyday life, professional conditions, and the level of sanitary culture of those living on the territory of the site, which makes it possible to achieve high efficiency of treatment and preventive work on the site. Therefore, compliance with the principle of locality is one of the important criteria for assessing the activities of the clinic. In this case, it is customary to use the following indicators:

• locality in service in a clinic, i.e. the ratio of the number of patients in one’s own area to the number of patients seen by a doctor;
• locality in home care, i.e. the ratio of the number of visits to patients at their site to the total number of visits made by the doctor.

High numbers of these indicators (within 80-90% and above) characterize the good organization of local-territorial therapeutic services.

The work of a local general practitioner includes the following sections.

1. Treatment of patients in the clinic and at home.
2. Preventive measures, among which the first place is occupied by medical examination of sick and healthy people.
3. Participation in hospitalization of patients.
4. Participation in the work of VKK and VTEK-
5. Referring patients to special treatment and diagnostic institutions, dispensaries, and sanatorium-resort institutions.
6. Health education.

The working time of a local physician-therapist is divided between work at the reception in the clinic and servicing calls at home. The following estimated workload standards for the local physician are provided: seeing 5 patients for 1 hour in the clinic and serving 2 patients for 1 hour at home.

Organization of work in the clinic. Modern City Polyclinic represents a multidisciplinary medical institution providing specialized medical care. It consists of one or more therapeutic departments and departments of other specialties (surgical, ENT, etc.). Each therapeutic department includes several local doctors. It is headed by a director - a well-trained, experienced therapist. Within the framework of the therapeutic department, special rooms are combined: adolescent, cardio-rheumatology, infectious diseases, etc. In addition, it is directly related to therapeutic service have dispensary rooms operating in some clinics (oncology, tuberculosis, etc.).

Each local doctor must have a weekly work schedule, designed so that the days morning appointment alternated with days of reception in the evening hours. This is necessary so that the patient can contact his local doctor at a time convenient for him. Such a schedule should be posted near the registration desk. To see patients during the absence of their local doctor, a doctor on duty is assigned to the clinic. However, the appointment of patients by the doctor on duty should be limited only to cases urgent need. In other circumstances, the patient should be advised to see his doctor during office hours.

When visiting a clinic, the patient goes to the reception desk, where he receives a voucher for an appointment with his local doctor or other specialist. Coupon for readmission issued by the doctor.
The main form of medical documentation in the clinic is the outpatient medical record (registration form No. 25). It is as important as the medical history of a patient being treated in a hospital. A card is created for each patient upon their first visit to the clinic. In addition to the passport part, which is filled out by the registrar, the doctor enters the following data into the outpatient card.

1. Patient interview data: his complaints, history of the present illness, brief life history, past illnesses, heredity, occupational hazards, etc.
2. The results of an objective examination, which should be focused and detailed.
3. Additional studies (laboratory, instrumental, consultations with other specialists) and their results.
4. Therapeutic and preventive measures, including work recommendations, diet and diet, medicinal purposes, physiotherapy, physical therapy, referral to a hospital, to a dispensary, to sanatorium-resort treatment, etc.

Due to the lack of time on the part of the clinician, all these notes must be reasonably concise.
The records of the head of the department, doctors of other specialties, as well as the results of additional and special studies are entered into the medical record of an outpatient patient. This allows any specialist, when visiting a patient, to familiarize himself in detail with his previous diseases. During treatment, the outpatient’s medical record is kept in the attending physician’s office, and the rest of the time it is stored at the clinic’s reception desk in a special file cabinet.

Severe, weakened and febrile patients should be cared for by a doctor at home. A doctor is called through the clinic's reception desk by the sick person himself (by telephone) or by his relatives, neighbors, etc. Calls are recorded by the registrar in the home care log, which is available to each local physician. After reviewing these records and those selected by the registrar outpatient cards sick, the doctor attends calls at appropriate times. The patient must be visited on the day of the call.
When visiting a patient, the doctor determines the diagnosis, prescribes treatment, and ensures that all necessary additional studies and treatment procedures are carried out. If necessary, the doctor should help organize care for the patient at the clinic or hospitalize the patient. Diagnostically unclear patients can be consulted at home by the head of the therapeutic department and doctors of other specialties.

If a patient with an infectious disease is detected at the site, the doctor is obliged to fill out and immediately send to the sanitary-epidemiological station an emergency notification card (registration form No. 58). In addition, each such case must be recorded in a special infectious diseases register (Form No. 60).
Modern equipment of clinics with laboratory and instrumental research methods allows, in most cases, to make a diagnosis and carry out treatment in outpatient setting. Indications for hospitalization of therapeutic patients are: the impossibility of establishing a reliable diagnosis using research methods available to the local doctor, and the characteristics of the disease (its nature, severity, etc.) requiring hospital treatment.

The closest assistant to the general practitioner is the local nurse. Her responsibilities include: assisting the doctor when receiving patients in the clinic; Carrying out medical prescriptions at the patient’s home; assistance in conducting medical examinations; maintaining medical records; conducting epidemiological surveys, vaccinations, ongoing disinfection and assisting the doctor in sanitary educational work and working with the sanitary assets of the site.

Local therapist plays a leading role in the public health system (in the future this will be a family doctor). The complex work of a local doctor combines medical and organizational activities (organization of prevention, treatment, medical examination, rehabilitation, sanitary education 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 also takes a direct part in the reception of patients (prepares the documentation necessary for the reception, writes prescriptions for medicines as directed by the doctor, fills out referral forms for examination, measures arterial pressure, body temperature, etc.) and carries out doctor’s orders at the site (does injections, puts mustard plasters, enemas, checks 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.

The clinic maintains a systematic record of patients in need of inpatient treatment in the “Registration Book of Patients Appointed for Hospitalization” (f. 034/u). To calculate the performance indicators of the clinic, the source of information is the annual report f.30. To assess the use of hospital beds, the following most important indicators are calculated: Provision of population with hospital beds, Average annual occupancy (work) of a hospital bed, Turnover of a hospital bed, Average length of stay of a patient in a hospital (average bed day), Hospital mortality (per 100 patients, in % ).

1. 28Organization of inpatient medical care. Structure of the city hospital, staff, organization of work. Hospital performance indicators.

Hospital is a medical and preventive institution that provides stationary for the population medical help, and in case of merger with a clinic, outpatient clinic help. Organizational forms of provision stationary assistance to the population, the structure of hospital facilities and their placement depend on the level and nature of morbidity and age and sex composition population, features of its settlement. In accordance with the nomenclature of healthcare institutions, a number of hospitals are designed to provide medical help predominantly rural to the population- regional (regional, republican), central regional and regional, as well as precinct. Rendering inpatient care children's to the population carried out in children's city, regional (regional, republican), district hospitals, as well as in children's departments of central district hospitals; obstetrics - in maternity hospitals and branches. By profile, multidisciplinary and specialized hospitals are distinguished (cardiology, infectious diseases, oncology, psychiatric, etc.). Hospitals are part of dispensaries, as well as medical units. Hospitals whose bed capacity is at least 50% used by medical universities for teaching or by medical research institutes for scientific purposes are called clinical.

City Hospital is a comprehensive treatment and preventive institution that provides inpatient care for the population the whole city or part of it. City hospitals are divided into eight categories depending on the number of beds available. In recent decades, development inpatient care followed the path of creating powerful institutions designed for 600 - 1000 beds. In such hospitals, significant material, technical and human resources can be concentrated, allowing the use of modern medical technology and achieve high efficiency of treatment and prophylactic help.

Tasks of the city hospital

Providing highly qualified specialized treatment and preventive hospital care help under the state guarantee program and voluntary health insurance programs.

Testing and implementation in healthcare practice modern methods treatment, diagnosis and prevention based on the achievements of medical science and technology, as well as the best practices of medical institutions.

Development and improvement organizational forms and methods of medical care help and nursing.

Creation of a therapeutic and protective regime.

Carrying out anti-epidemic measures and preventing nosocomial infections.

Carrying out sanitary and educational work, hygienic education population and promoting a healthy lifestyle.

Improving the quality of treatment and prevention help, wide involvement of the public in the development and implementation of activities aimed at improving treatment and prevention assistance to the population.

The city hospital is managed by chief physician, who is appointed and dismissed by a higher health authority or may be elected by a staff meeting. The chief physician has deputies for medical work, for outpatient work (if there is a polyclinic within the hospital), for the examination of work ability, and for economics. Large multidisciplinary hospitals may introduce positions of deputy chief physician in certain areas of work. The chief physician manages the hospital with the rights of sole command. Together with his deputies, he is responsible for organization, the level and quality of the treatment and diagnostic process in the institution, is responsible for the state of the material and technical base and compliance with sanitary and anti-epidemic requirements, ensures advanced training of all hospital staff, using for this purpose institutes for advanced training of doctors, faculties for advanced training and an in-hospital system of classes, medical and nursing conferences .

The staffing of hospitals is determined by the staffing table approved by the head of the institution within the limits of the planning fund established by a higher authority wages. Until 1989, the procedure was in force according to which the hospital staffing table was formed on the basis of staffing regulations (orders) and approved by the health authority under whose direct control the hospital was located. Currently, all previously valid regulatory documents are only advisory in nature, and the chief physician of the hospital, based on the specific tasks assigned to the institution, determines the required number of staff positions in the hospital departments.
Basic structural unit The treatment and prophylactic part of the hospital is a specialized medical department, headed by the head, who is appointed and dismissed by order of the chief physician. The head of the department directly supervises the work of the residents and, through the head nurse of the department, the work of the nursing staff.

The departments consist of 30-70 or more beds and use all the hospital’s medical and diagnostic services in their activities.

Emergency room (rest) is important structural unit hospital, and the success of further treatment largely depends on how well its work is organized. As a rule, patients are admitted to hospitals on a planned basis in the direction of outpatient clinics and on an emergency basis when they are referred and delivered by ambulance. A small proportion of patients (3 - 5%) are admitted to the hospital “by gravity,” that is, by going to the emergency department on their own. During planned hospitalization, clinic doctors draw up special documents (a referral for planned hospitalization, which indicates the results of the latest outpatient studies, recommendations of specialist consultants, treatment measures taken, duration of temporary disability, purpose of hospitalization). For full-fledged work, the reception department must have a sufficient number of premises (2-3 isolated examination rooms, a sanitary inspection room, wards intensive care and isolation of patients, an office of the doctor on duty), a constant supply of medicines and first aid supplies, the ability to conduct urgent laboratory and X-ray and other studies.

IN reception department clarify or establish a diagnosis, prescribe and carry out the necessary treatment, provide emergency medical care if necessary and decide on the validity of hospitalization. A patient is admitted to a hospital by the doctor on duty at the emergency department (hospitals I–IV categories) or the doctor on duty at the hospital, who is obliged to ensure a timely examination of the patient, familiarize himself with the medical documentation and, if indicated, hospitalize him in the appropriate department of the hospital. Doctors in the hospital's emergency department work closely with doctors in the hospital's departments and have the opportunity to call doctors of other specialties, who are on duty in their department at the time, to consult the patient. In the event of a refusal to admit a patient, the doctor on duty makes an entry in a special journal about the reasons for the refusal to hospitalize and the measures taken - medical care provided, referral to another institution, etc. Information about each hospitalized person is entered into the patient admission register, and the passport part of the inpatient medical record is filled out for it.

Hospital treatment departments are usually formed according to the pathology profile (therapy, surgery, gastroenterology, traumatology, etc.). The profile of hospital beds is established by a higher health authority to ensure that the population's needs for inpatient care are met. Depending on the tasks solved by a particular hospital, the size of the population served and its need for various types Medical aid structural units of a hospital may have different capacities. The optimal capacity of a department in a large hospital is 60 beds.

The examination and treatment of patients admitted to the department is carried out by a resident with the constant assistance and participation of the head of the department.

Functional responsibilities of a hospital resident

Provides qualified medical care to hospitalized patients using the necessary diagnostic tests and treatment methods based on modern achievements science and practice;

Conducts daily rounds of patients, participates in rounds of the head of the department, reporting to him about patients under observation, and in some cases consults with medical specialists;

Prescribes medications and other treatments, medical procedures, nutrition, regimen, appropriate care and is responsible for the implementation of the appointments made, independently conducts special types of research in accordance with the profile of the department;

Maintains medical records of inpatients by daily recording data on the condition of patients, their treatment, nutrition, regimen, etc. When patients are discharged, an epicrisis is drawn up - short conclusion about the course of the disease and the patient’s condition at the time of discharge;

Maintains the medical and protective regime in the departments;

Monitors the sanitary and hygienic condition of the department, carries out the prevention of nosocomial infections, strictly adheres to the anti-epidemic regime;

Conducts health education work with patients;

Supervises the work of the middle and junior staff subordinate to him, checks the correctness and timeliness of all assignments.

The effectiveness of treatment and preventive measures in a hospital largely depends on the organization of an appropriate treatment and protective regime. The therapeutic and protective regime provides for the creation of favorable conditions for effective treatment, moral and mental peace, confidence of patients in a quick and complete recovery. Medical personnel must be attentive and sensitive to patients, avoid inappropriate conversations in the presence of patients, noise in hospital corridors, and strictly adhere to the daily routine in the departments. The assessment of the hospital’s activities is carried out on the basis of an analysis of the report of the medical institution. In this case, it is necessary to separately consider indicators characterizing the volume and organization of work (composition of beds, average annual bed occupancy, average length of stay of a patient in a bed, bed turnover, etc.) and the quality of hospital activities (frequency postoperative complications, hospital mortality, etc.).

Methodology for calculating and analyzing general performance indicators

hospital

1. Provision of population with inpatient care (per 10 thousand population)

Average annual number of beds? 10000

Total population

The standard number of beds per 10,000 people is a total of 121.8 beds, including therapeutic beds - 20.35, pediatric 1.68, dental - 0.44, surgical - 10.45, obstetric - 3.75, gynecological - 6, 07, cardiological – 2.96.

2. Hospitalization rate (per 1000 population)

The number of patients who left the hospital (discharged + died)? 1000

Total population

Expected number of hospitalizations. Total per 1000 population - 243.0, including: therapy - 39.42, pediatrics - 4.39, dentistry -1.16, surgery -28.71, obstetrics - 12.58, gynecology -23.64.

3. Average annual occupancy of a hospital bed (function of a hospital bed)

Bed days spent by patients

Average annual number of beds

In general, for the hospital and for most departments, the standard is 320 days a year. Exceptions are infectious diseases departments, maternity hospitals, specialized children's departments, in which the average annual employment is lower due to the peculiarities of the sanitary and epidemiological regime in these institutions and ranges from 250 to 300 days a year.

4. Average length of stay of a patient in bed

Bed days spent by patients

Number of retired (discharged + deceased) patients

Actual average duration A patient’s stay in a multidisciplinary hospital in the Russian Federation is currently 12-14 days, in Stavropol region– 10-12 days, including in therapeutic departments – 13.5, in surgical departments – 11, maternity departments – 7, trauma departments – 15, tuberculosis departments – 60 days.

5. Bed turnover

Number of retired (discharged + died) patients

Average annual number of beds

The indicator gives an idea of ​​the number of patients treated in a hospital during the year in one bed. Depends on average duration stay of the patient in bed per year. Bed turnover in urban areas hospital facilities according to planned standards it is approximately 22-24 times. The bed turnover rate is calculated both for the hospital as a whole and for departments.

6. Bed downtime

Number of days per year (365) – actual number of days the bed is occupied per year

Bed turnover

The indicator characterizes the average bed downtime from the moment the previous patient is discharged until the next patient is admitted and is 1-2 days in the Russian Federation.

7. Hospital mortality (%)

The number of patients who died in hospital? 100

Number of retired (discharged + deceased) patients

Assessing the indicator is difficult, since there are not and cannot be any mortality standards. Mortality depends on the composition of patients in the department, age, gender of patients, severity of the disease, timeliness of hospitalization, previous outpatient treatment, etc. Hospital mortality in the Russian Federation is 1.5% in hospitals for adults and adolescents and 0.4% in hospitals for children, including in connection with tuberculosis of the respiratory system - 7.1%, sepsis - 22.6%, neoplasms - 5.8%, diseases of the respiratory system - 1.0%, diseases of the circulatory system - 4.6% heart attack myocardium – 43.1%.

8. Structure of hospitalized patients by individual nosological forms of diseases

The number of people leaving the hospital with one nosological form of the disease? 100

Number of all patients leaving the hospital

Calculated for several forms of diseases

9. Structure of causes of hospital mortality

The number of patients who died with one nosological form in the hospital? 100%

Number of patients who died in hospital

Calculated for each form of the disease

10. Postoperative mortality

The number of patients who underwent surgery died? 100

Number of operated patients

The postoperative mortality rate in the Russian Federation is 0.5 – 0.7%, in the Stavropol Territory – 0.76%

Number of average annual beds in a hospital (department)

Number of occupied medical positions in hospitals

In most departments, the doctor’s workload is 20-25 beds per position, but there are departments with a lower (maternity and children’s boxed - 15 beds) and higher load (phthisiatric - 35, psychiatric - up to 50 beds).

29Primary health care for the population of the Republic, its organization

Primary health care is provided by local therapists, pediatricians, general practitioners, paramedics, obstetricians and nurses (hereinafter referred to as primary health care specialists).
5. Primary health care is provided in accordance with standards (lists of services, operations and manipulations, medicines and products medical purposes), approved by the authorized body in the field of healthcare (hereinafter referred to as the authorized body).
6. The following types of services are provided within the framework of primary health care:
preventive, diagnostic, therapeutic, examination of temporary disability.
7. Preventive services include: preventive examinations, immunization, formation and promotion of a healthy lifestyle, recommendations for a rational and healthy diet, family planning, medical examination and dynamic observation, patronage of pregnant women, children, including newborns, social and psychological counseling.
8. Diagnostic services include: examination by a primary care specialist, laboratory and instrumental studies.
9. Treatment services include: provision of emergency and emergency medical care, medical procedures in accordance with health care standards, provision of certain categories of citizens with certain diseases (conditions) with free or discounted medicines and specialized medicinal products on an outpatient basis.
10. When providing primary health care, an examination of temporary disability is carried out in the manner established by the Government of the Republic of Kazakhstan. An examination of temporary disability is carried out by a doctor for the purpose of officially recognizing the disability of an individual and his temporary release from work duties for the period of illness.
11. Primary health care is provided within the framework of the list of guaranteed volumes of free medical care (hereinafter - GVFMC), approved by the Government of the Republic of Kazakhstan.
12. Primary health care is provided to citizens:
1) regardless of the fact of attachment in case of emergency and emergency medical care;
2) in a planned manner - by attachment, pre-registration or application.
13. When a citizen first contacts a primary health care organization, a medical record of an outpatient or a child’s development history, which are the primary accounting medical documents, is drawn up at the registry of the primary health care organization.
Primary medical records used in primary health care organizations are filled out only on the appropriate forms approved by the authorized body and are stored in the registry of the medical organization.
Ensuring the safety of primary medical records is carried out by a senior registrar, and in paramedic-obstetric and medical centers - by a primary care specialist, in the manner established by the authorized body.
14. A citizen who, due to health conditions and the nature of the disease, cannot come to an appointment at a PHC organization, medical care is provided at home by PHC specialists, or by specialized specialists at the request of PHC specialists on the day the call is registered.
15. When providing primary health care, the attending physician writes out prescriptions for medications. Medicines are prescribed only on approved prescription forms without indicating a specific pharmacy organization, in the manner approved by the Government of the Republic of Kazakhstan.
16. Dispensing of medicines and biologically active additives medical workers PHC organizations are not allowed, with the exception of specialists with medical education certified for this type of activity (medical outpatient clinics, medical and feldsher-obstetric stations in populated areas who do not have pharmacy facilities).Primary health care is basic, accessible and free

for each citizen a type of medical care and includes: treatment of the most

common diseases, as well as injuries, poisonings and other emergency conditions;

medical prevention major diseases; sanitary and hygienic education

nie; carrying out other activities related to the provision of health care

citizens at their place of residence.

Primary health care, incl. medical care for women in pe-

period of pregnancy, during and after childbirth is provided by institutions of the municipal system-

healthcare topics mainly at the place of residence, outpatient

polyclinic institutions: outpatient clinic, general medical (family) practice center

ki, district (including central), city clinic, children's city clinic

Nika, Women's consultation. In the provision of primary health care may also

institutions of public and private health care systems participate on a contractual basis

thieves with insurance medical organizations.

Primary health care is provided by medical professionals given

institutions: local therapists, local pediatricians, general practitioners

tics (family), obstetricians-gynecologists, other medical specialists, as well as

cialists with secondary medical and higher nursing education.

Citizens have the right to free medical care in state and municipal

municipal health care systems. Guaranteed volume of free medical care

assistance is provided to citizens in accordance with the State Guarantee Program

ties to provide free medical care to citizens of the Russian Federation.

Outpatient care includes:

providing first (pre-hospital, medical) and emergency medical care

patients with acute diseases, injuries, poisoning and other emergency conditions;

carrying out preventive measures to prevent and reduce disease

income, abortions, identification of early and latent forms of diseases, socially significant

diseases and risk factors;

diagnosis and treatment various diseases and states; restorative

clinical expert activities to assess the quality and effectiveness of medical and

diagnostic measures, including examination of temporary disability;

dispensary observation of patients, including certain categories of citizens,

eligible to receive the kit social services;

prophylactic medical examination of pregnant women and postpartum women; medical examination of healthy and

sick children;

dynamic medical observation of the child’s growth and development;

organization of children's nutrition early age;

organization of additional free medical care for individual categories

for citizens, including the provision of necessary medicines;

establishment of medical indications and referral to government agencies

healthcare systems for receiving specialized types of medical care;

establishing medical indications for spa treatment, including

medical care for students, pupils of educational institutions

tions of general and correctional types; carrying out sanitary-hygienic and anti-epidemic measures

medical activities, vaccinations in the prescribed manner;

implementation of sanitary and hygienic education, including on issues

formation of a healthy lifestyle;

medical consultation and medical career guidance;

medical support for the preparation of young men for military service.

Inpatient care provided to the population of municipalities in

hospital and inpatient clinics, includes:

providing emergency medical care to patients with acute diseases,

injuries, poisoning and other emergency conditions;

diagnosis, treatment of acute, chronic diseases, poisonings, injuries, conditions

tions in the pathology of pregnancy, during childbirth, in postpartum period, during abortions and others

conditions requiring round-the-clock medical supervision or isolation due to epidemiological

mic indications;

restorative treatment and rehabilitation.

Hospitalization in a hospital (in-patient clinic) institution was carried out

for medical reasons:

by direction of a doctor of a medical institution, regardless of

forms of ownership and departmental affiliation;

emergency medical care;

when a patient self-refers for emergency reasons.

1. 30Territorial city clinics, their tasks and organization of work. Structure of a city clinic.

A polyclinic is a medical and preventive institution that provides medical care to incoming patients, as well as treatment of patients at home.

The main tasks of the city clinic (outpatient department of the city hospital):
-providing qualified specialized medical care to the population of the serviced area directly in the clinic and at home;
-organization and implementation of preventive measures to reduce morbidity, disability and mortality among the population of the serviced area and workers of attached industrial enterprises;
-organization and implementation of clinical examination of the population (healthy and sick), especially adolescents, workers of industrial enterprises and construction sites, as well as persons with disabilities increased risk the occurrence of diseases in patients with cardiovascular, oncological and other diseases;
- organizing and conducting events for sanitary and hygienic education of the population, promoting a healthy lifestyle (rational nutrition, physical activity), combating bad habits.

To perform these tasks, the city clinic ( outpatient department city ​​hospital) carries out the following:
-providing first and emergency medical care to patients with acute diseases, as well as injuries, poisoning, etc.;
-providing qualified medical care at home for patients who, due to health conditions and the nature of the disease, cannot visit the clinic, need bed rest and systematic medical supervision;
- timely and qualified provision of medical care at an appointment at the clinic;
-early detection of diseases, qualified and full examination of sick and healthy people who applied to the clinic;
- timely hospitalization of persons in need of hospital treatment, with a preliminary maximum examination of patients in accordance with the nature of the disease;
-medical rehabilitation(in the rehabilitation treatment department) for patients with cardiovascular diseases, with consequences of disorders cerebral circulation, diseases and injuries of the musculoskeletal system, involving for this purpose doctors of relevant specialties (cardiologist, neurologist, rheumatologist, traumatologist, etc.);
-all types of preventive examinations (mandatory preliminary upon entry to work, periodic, targeted, etc.);
- clinical examination of the population - selection of persons (healthy and sick) subject to dynamic medical supervision, systematic qualified examination and treatment of those undergoing medical examination, study of their working and living conditions, development and implementation of necessary preventive measures;
- dynamic monitoring of the health status of adolescents (teenage workers, students of vocational schools, students of secondary specialized schools and students of higher educational institutions), study of their working and living conditions, implementation of therapeutic and recreational activities;
- anti-epidemic measures (together with the SES) - vaccinations, identification of infectious patients, dynamic monitoring of persons who have been in contact with infectious patients and convalescents, alarm of the sanitary-epidemiological station, etc.;
-examination of temporary and permanent disability of patients (workers and employees), issuance and extension of certificates of incapacity for work, determination of work recommendations for those in need of transfer to another job, selection for sanatorium treatment;
- referral to medical labor expert commissions (VTEK) of persons with signs of permanent disability;
- sanitary and educational work among the population served, adolescents and workers of industrial enterprises, their hygienic education;
-accounting for the activities of personnel and departments of the clinic;
-involving public activists of the district to assist in the work of the clinic and organizing control over its activities;
-measures to improve the qualifications of doctors and nursing staff (referral through a rotation system to hospitals, continued.
-measures to improve the qualifications of doctors and paramedical personnel (direction through a rotating system to hospital inpatient units, institutes for advanced training of doctors, holding seminars, ten-day events, etc.).

structure.
There is a longer version, but I think this is enough.

In accordance with the tasks and functions of the city clinic, its approximate organizational structure, which provides the following divisions:
registry;
prevention department (offices pre-medical appointment, organizing control over the medical examination of the population and maintaining a centralized card index of persons registered at the dispensary, an office for identifying persons with an increased risk of disease - anamnesis, an office for health education and hygienic education of the population, an office for preventive examinations of individual contingents, an examination room for women);
treatment and preventive units (therapeutic, traumatological, dental department etc., medical and paramedic health centers);
auxiliary diagnostic units (X-ray department, laboratories, functional diagnostics department, etc.).

1. 31 Medical examination of the population. Problems of medical examination at the present stage.

The activities of a local general practitioner are regulated by Order of the Ministry of Health and Social Development of the Russian Federation No. 765 of December 7, 2005 “Regulations on the organization of activities of a local physician-therapist”. Below is Appendix No. 1 to the above Order.

1. These Regulations regulate the activities of the local general practitioner.

2. Specialists with a higher education degree are appointed to the position of local physician-therapist medical education in the specialty "General Medicine" or "Pediatrics" and a specialist certificate in the specialty "Therapy".

3. The local therapist in his activities is guided by the legislation of the Russian Federation, regulatory legal acts federal body executive power in the field of healthcare, executive authorities of the constituent entities of the Russian Federation and local governments, as well as this Procedure.

4. A local physician carries out his activities to provide primary health care to the population in medical organizations primarily in the municipal health care system:

Clinics; - outpatient clinics;

Inpatient clinics of the municipal health care system;

Other medical and preventive institutions providing primary health care to the population.

5. Remuneration (financing of activities) of a local physician-therapist is carried out in accordance with the legislation of the Russian Federation.

6. Local therapist:

Forms a medical (therapeutic) site from the population attached to it;

Provides sanitary and hygienic education, advises on the formation of a healthy lifestyle;

Carries out preventive measures to prevent and reduce morbidity, identify early and latent forms of diseases, socially significant diseases and risk factors, organize and conduct health schools;

Studies the needs of the population it serves for health-improving activities and develops a program for carrying out these activities;

Carry out dispensary observation of patients, including those entitled to receive a set of social services, in the prescribed manner;

Organizes and conducts diagnostics and treatment of various diseases and conditions, including rehabilitation treatment of patients on an outpatient basis, day hospital and hospital at home;

Provides emergency medical care to patients with acute diseases, injuries, poisoning and other emergency conditions in an outpatient setting, day hospital and home hospital;

Refers patients for consultations with specialists, including for inpatient and rehabilitation treatment for medical reasons;

Organizes and carries out anti-epidemic measures and immunoprophylaxis in the prescribed manner;

Conducts an examination of temporary disability in the prescribed manner and draws up documents for referral to medical and social examination;

Issues a conclusion on the need to refer patients for medical reasons to sanatorium-resort treatment;

Interacts with medical organizations of state, municipal and private healthcare systems, medical insurance companies, and other organizations;

Organizes, together with the social protection authorities, medical and social assistance to certain categories of citizens: single, elderly, disabled, chronically ill, in need of care;

Manages the activities of nursing staff providing primary health care;

Maintains medical documentation in the prescribed manner, analyzes the health status of the assigned population and the activities of the medical area.

The local therapist prepares Passport of the medical unit (therapeutic)(see Attachment).

In his work, the local general practitioner is also guided by Order of the Ministry of Health and Social Development No. 255 of November 22, 2004 “On the procedure for providing primary health care to citizens entitled to receive a set of social services.” Below are extracts from this Order.

In accordance with clause 5.2.11. Regulations on the Ministry of Health and Social Development of the Russian Federation, approved by Decree of the Government of the Russian Federation of June 30, 2004 N 321 (Collected Legislation of the Russian Federation, 2004, N 28, Art. 2898), art. 6.1., 6.2. Federal Law dated July 17, 1999 N 178-FZ "On State social assistance"(Collected Legislation of the Russian Federation, 1999, No. 29, Art. 399; 2004, No. 35, Art. 3607) and for the purpose of providing primary health care to citizens entitled to receive a set of social services,

I ORDER:

1. Approve:

1.1. The procedure for providing primary health care to citizens entitled to receive a set of social services (Appendix 1).

1.2. Registration form N 025/u-04 “Medical record of an outpatient” (Appendix 2).

1.3. Registration form N 025-12/у "Outpatient Patient Certificate" (Appendix 3).

1.4. Registration form N 030/у-04 “Dispensary observation control card” (Appendix 4).

1.5. Registration form N 057/u-04 “Referral for hospitalization, rehabilitation treatment, examination, consultation” (Appendix 5).

1.6. Registration form N 030-P/u “Passport of the medical district of citizens entitled to receive a set of social services” (Appendix 6).

1.7. Registration form N 030-Р/у “Information on medicines prescribed and dispensed to citizens entitled to receive a set of social services” (Appendix 7).

1.8. Instructions for filling out registration form N 025/u-04 “Medical record of an outpatient” (Appendix 8).

1.9. Instructions for filling out registration form N 025-12/у "Outpatient Card" (Appendix 9).

1.10. Instructions for filling out registration form N 030/у-04 “Dispensary observation checklist” (Appendix 10).

1.11. Instructions for filling out registration form N 057/u-04 “Referral for hospitalization, rehabilitation treatment, examination, consultation” (Appendix 11).

1.12. Instructions for filling out registration form N 030-P/u “Passport of the medical district of citizens entitled to receive a set of social services” (Appendix 12).

1.13. Instructions for filling out registration form N 030-Р/у “Information on medicines prescribed and dispensed to citizens entitled to receive a set of social services” (Appendix 13).

Minister M.Yu. ZURABOV

Appendix No. 1 to the Order

Ministry of Health and Social Development

Russian Federation dated November 22, 2004 N 255

PROCEDURE FOR PROVIDING PRIMARY HEALTH CARE TO CITIZENS HAVING THE RIGHT TO RECEIVE A SET OF SOCIAL SERVICES

1. This Procedure regulates the provision of primary health care to citizens entitled to receive a set of social services (hereinafter referred to as citizens) in institutions providing primary health care.

2. When citizens apply to an institution providing primary health care, a “Medical record of an outpatient patient” (registration form N 025-12/u) or “History of child development” (registration form N 112/u) marked with the letter "L".

An outpatient card is filled out (registration form N 025-12/у), with which the citizen is sent to an appointment with a local doctor or paramedic.

3. During the initial medical examination of the patient, the local therapist, local pediatrician, general practitioner (family doctor), paramedic conducts an in-depth examination with the participation of the necessary specialists, establishes a clinical diagnosis, determines an individual plan of treatment and health measures and the procedure for dispensary observation, in accordance with which An entry is made in the “Dispensary Observation Control Card” (form N 030/у-04).

4. Mandatory dispensary observation is carried out according to the following scheme: once a year - an in-depth medical examination with the participation of the necessary specialists, once every six months - additional laboratory and instrumental examination, once every 3 months - patronage by a local nurse.

If a patient has a disease that requires individual clinical observation, the attending physician carries out clinical observation according to an individual plan corresponding to the given disease.

5. Local therapist, local pediatrician, general practitioner (family doctor), paramedic performing dispensary observation:

Organizes, in accordance with the standards of medical care approved in the prescribed manner, at the outpatient stage, treatment of patients both in a primary health care institution and in a day hospital (in a hospital at home);

If necessary, refers patients for consultation with specialists or for hospitalization;

If the patient is unable to visit an outpatient clinic, he will organize medical care at home.

6. A local therapist, a local pediatrician, a general practitioner (family doctor), a paramedic, a medical specialist who has the right to issue a prescription, prescribes medications provided for in the “List of Medicines” approved by the Order of the Ministry of Health and Social Development of the Russian Federation dated 02.12. .2004 N 296 “On approval of the list of medicines” (registered by the Ministry of Justice of the Russian Federation on December 7, 2004, registration N 6169), in accordance with the standards of medical care approved in the prescribed manner.

In case of insufficiency of pharmacotherapy during treatment individual diseases for vital indications and when there is a threat to the life and health of the patient, other medications may be used by decision of the medical commission, approved by the chief physician of the medical institution.

7. A local therapist, a local pediatrician, a general practitioner (family doctor), a paramedic, if there are indications and no contraindications, prescribes sanatorium-resort treatment for each citizen, in accordance with his illness, with filling out a certificate for obtaining a sanatorium-resort voucher and registering a sanatorium -resort card.

8. When issuing prescriptions (registration form N 148-1/у-04 (l), certificates for obtaining health resort vouchers(registration form N 070/u-04), registration of sanatorium-resort cards (registration form 072/u-04) or (076/u-04 - for children), a mark is made in the relevant accounting documentation, which is marked with the letter “L”.

9. A local therapist, a local pediatrician, a general practitioner (family doctor), and a paramedic draws up a “Passport of the medical district of citizens entitled to receive a set of social services” (registration form N 030-P/u).

10. In order to maintain continuity in the organization of medical care, when a child reaches the age of 17 years (inclusive) and is transferred for medical care to an outpatient clinic institution of the general medical network, data from the history of the child’s development (registration form N 112/у) is transferred to " Insert sheet for a teenager to the outpatient medical record" (registration form N 025-1/у), which is transferred to the outpatient clinic at the place of residence.

11. The organizational and methodological office of an institution providing primary health care to citizens entitled to receive a set of social services (medicine, sanatorium and recreational treatment), monitors the medical care provided and provides the head physician of the institution with information about work with citizens eligible to receive a set of social services at least once a quarter.

In providing qualified therapeutic assistance Diagnosis of the condition plays an important role, which the patient contacted his local physician.

As the first contact doctor, the local general practitioner sees the patient or at the onset of acute illness when the disease is represented by a monosymptom: fever with a single chill, diarrhea, pain, etc. Or another situation concerns the diagnosis of multimorbid suffering with a mass of heterogeneous symptoms, when you have to decide: is it one disease with many symptoms, or many diseases, each of which has its own symptoms.

In addition, unlike a hospital doctor, a local therapist, as a rule, is in three situations: either he sees a patient who has turned to him for help for the first time, or a patient whom he has known well for a long time has turned to him for help. In the latter case, it is easier for the local doctor to solve the diagnostic problem. But there is a third situation - when a “familiar” patient comes, with “old” diseases, and subtle initial symptoms of a new disease may go unnoticed or be adjusted to a previously existing disease.

In any case, the diagnosis “goes” from symptom to syndrome. Syndrome is a group of clinical, instrumental, laboratory symptoms that are pathogenetically related to each other. In typical cases of acute illnesses (sore throat, influenza and acute respiratory viral infections, acute pneumonia, myocardial infarction, etc.) the diagnosis is made by the method of direct substantiation, when the symptoms of the disease constitute a simple syndrome that appears in a nosological form. When making a diagnosis by direct substantiation, identification of the disease is carried out by comparing the symptoms of the disease in the patient with classical description disease clinics in medical literature.

Differential diagnosis is necessary when the patient does not have the full range of typical symptoms for the disease. "Gold standard" scheme differential diagnosis- from symptoms to the leading syndrome, from it through a diagnostic algorithm to a nosological diagnosis. The leading syndrome is selected so that it occurs in a limited range of diseases. The construction of a diagnostic algorithm is based on the principle of optimal diagnostic feasibility, when reliable diagnosis is carried out on the basis of a minimum of signs identified with a minimum medical research. When creating a diagnostic algorithm, a minimum of decisive symptoms (diagnosis criteria) are taken into account, which are used for subsequent intrasyndromic differentiation. What is important is the optimal sequence of recording and interpretation of decisive symptoms with subsequent differential diagnosis of all diseases manifested by this leading syndrome. In addition, it should be specially noted that it is extremely important for the local general practitioner to find out, using anamnesis and physical examination, where in-depth laboratory and technical diagnostics are needed, and where you can do without it. At the same time, in order to solve only one “fixed” problem, a general practitioner often has to refuse a comprehensive history and examination (for example, in case of acute respiratory infections or influenza).

Having established a nosological diagnosis based on diagnostic criteria, a description of the characteristics of the course of the disease in a given patient is given. This is the stage, phase of the disease, activity of the process, course, function of organs and (or) systems (Galkin V.A., 2000).

If a patient suffers from many diseases, one of them is the main one. This is the nosological form that itself or as a result of complications causes given time the primary need for treatment due to the greatest threat to life and disability; in cases of patient death, the underlying disease during the outcome period or through complications is its direct cause. Complications are pathogenetically related to the underlying disease; they contribute to an unfavorable outcome of the disease, causing a sharp deterioration in the patient’s condition. In the diagnostic formula, the “complications” heading is placed on a separate line; the date and hour of occurrence of each of the complications must be indicated.

A background disease is a nosological form that contributes to the occurrence or unfavorable course of the underlying disease, increases its danger to work capacity and life, contributes to the development of complications and therefore requires treatment at a given time along with the underlying disease. Concomitant disease- a nosological unit that is not etiologically and pathogenetically related to the underlying disease, does not have a significant impact on its course, and is significantly inferior to it in terms of the degree of influence on its course, in terms of the degree of need for treatment. Competing diseases are nosological units present simultaneously in a patient, independent of each other in etiology and pathogenesis, but equally meeting the criteria of the underlying disease.

Regular combinations of diseases are called syntropies. The most common of these is that the patient has coronary disease heart disease, hypertension, obesity, diabetes mellitus, cholelithiasis, deforming osteoarthritis. Knowledge of syntropies facilitates the diagnostic search and limits the range of expensive examinations.

Diagnostic formulations are different for an acute disease, at the peak of an exacerbation, with a fading exacerbation, in the remission stage of a chronic disease. Correct formulation of the diagnosis of acute illness and exacerbation chronic disease taking into account the stage, phase, severity, leading clinical syndromes, functional characteristics affected organs is the basis for adequate therapeutic measures. For several diseases in one patient, the choice of treatment method is determined by the nature of the underlying disease and its complications, taking into account background and concomitant diseases, the patient’s personal characteristics, and his attitude to the disease. A competent formulation of a clinical diagnosis is the most important tool for treating a patient.

Treatment of the patient. It is well known that treatment should be etiotropic, pathogenetic, and, if indicated, symptomatic. In a clinic setting, the prescribed set of medical and health procedures should be minimal and not burdensome for the patient, including from an economic point of view. The first record is a record of the regime, which for an outpatient patient can be: outpatient, home, bed, sanatorium and day hospital. The next entry is about diet. Then the necessary medications are indicated with doses and frequency of administration. The patient should be an “ally” of the doctor in the implementation of treatment and he should be briefly and clearly told about the effect of each of the prescribed drugs. It must be borne in mind that often in this situation, treatment may be “interfered” with family members who already know this drug with negative side. It is extremely important to understand the patient’s personal characteristics before starting treatment, then the treatment conversation will be more effective. Any experienced doctor knows: it is easy to talk about the treatment of diseases, but it is difficult to treat the patient. Difficulties arise from the fact that the laws of statistics are broken against the reef of individuality. There is a well-known expression: to treat not the disease, but the patient. Individualization of treatment is certainly necessary, but there cannot be hundreds and thousands of treatment options for patients suffering from the same type of disease. The treatment program is usually built in accordance with the typology of the disease, which is determined by a combination of a number of factors: nosology, severity, rate of progression of organ pathology (target organs), background diseases, age and gender of the patient, personal reaction to the disease.

Diagnostic and therapeutic procedures are prescribed in accordance with existing forms, protocols, and medical and economic standards. Medical and economic standards are compiled in the form of unified tables, which include the following headings: profile (large nosological group), name of the disease and its additional characteristics, ICD-10 code, mandatory volume of diagnostic tests, quality criteria for treatment in a hospital and in a clinic, category of complexity supervision of the patient. Territorial medical and medical-economic standards are used to establish the volume of medical services for each insured person in accordance with his illness, and to assess the quality of medical services.

A local general practitioner familiar with medical and medical-economic standards carries out self-control in accordance with them and adequately evaluates advisory assistance specialist In Russia, the so-called The formulary system is a reference book for any doctor on treatment.

Thus, the provision of qualified therapeutic assistance by a local therapist includes the following features:

1) he receives patients in the clinic and provides home calls (by meeting with him, patients judge the entire healthcare system),

2) the local doctor often deals with undifferentiated pathology and diagnoses at an early stage,

3) when making a diagnosis, in a limited time interval, the doctor generalizes both subjective, physical, psychological, social factors,

4) during every interaction with a patient, he shows alertness in terms of cancer pathology, tuberculosis, HIV infection (other infectious diseases),

5) must know medical and economic standards for the provision of diagnostic and treatment care, forms of the Ministry of Health of the Russian Federation for treatment,

6) must know and master the technology of providing emergency (prehospital) care,

7) all actions and decisions of the local doctor must have a preventive focus,

8) daily work requires high skill in communicating with people (the patient, his relatives, with related specialist consultants),

9) the local general practitioner carries out constant monitoring of patients with chronic, exacerbating or terminal diseases,

10) the local general practitioner must know the state of drug supply,

11) ensure continuity in the implementation of diagnostic and treatment care,

12) be aware of the sanitary and epidemiological situation in your area,

13) make decisions on all the problems of the patient who contacts him.

We would especially like to draw attention to the problem of healing, which is sometimes addressed in outpatient clinics by both doctors and patients. Let us cite the corresponding article from the “Fundamentals of Legislation...”.