Child's medical record: form, filling details and requirements.

In almost all developed countries Mandatory medical examination of adults and children is provided. Such measures are regulated by the Ministry of Health and are aimed at protecting the health of citizens. The forms of certificates can be very diverse and depend on what specific team the person will be in. Our country has developed a whole system of documents for these purposes.

In this article we will study the issue of registering and obtaining a certificate, without which a 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 for your baby to start going to kindergarten. We will talk about the child’s medical record form 026/u, since parents are interested in what information it should contain and how it is processed.

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 his first visit to a general education institution.

Let's consider the medical documents necessary for enrollment in a school or kindergarten. These include:

F-63 preventive vaccination card;

Medical card F-026u;

Vaccination certificate (blue book);

Compulsory medical insurance policy;

Information about the epidemiological environment.

Why do you need a medical card?

Form 026/у is required for the child to be accepted into the team kindergarten or a general education institution. Carrying out the examination required to obtain the card is important point not only to avoid the outbreak of epidemics in a group of preschoolers, but also to monitor the health status of children. That is, in essence, this is a preventive measure. It must be remembered that timely detected pathology gives a high chance of its complete elimination without consequences. What else does a child’s medical record provide?

If health problems are identified

In addition, if during the examination a child’s health problem is diagnosed, he may be sent to a specialized preschool institution, and parents will receive special recommendations regarding further actions. If vision problems are detected, parents are advised to consider the option of a special kindergarten for children with such pathologies. Such recommendations are not something terrible; on the contrary, they are aimed at ensuring that the child receives specialized assistance in restoring vision. Such kindergartens focus their activities on improving the health of children with vision pathologies.

If a student is diagnosed with pathologies that do not allow high-intensity physical exercise, the pediatrician can issue a special permit for not attending physical education classes at school. It can be either temporary, until the problem is resolved, or permanent.

Visiting specialists

The main question for all parents is which specific specialists need to be visited to obtain a certificate. Medical card child care involves consultation with a wide range of doctors. To obtain it, first of all, you should visit a pediatrician. He will issue the necessary referrals to specialists, including tests.

List of doctors

Typically, the list of required specialists includes:

1. Neuropathologist.
2. Oculist.
3. Surgeon.
4. Orthopedist.
5. Otolaryngologist.
6. Dermatologist.
7. Dentist.

If the child suffers from any illness in chronic form, then, at the discretion of the pediatrician, referrals to other specialized specialists, such as a speech therapist, gynecologist, psychologist, endocrinologist or andrologist, can be issued. The Ministry of Health recommends seeing a gynecologist for girls and an andrologist for boys starting at age 14. This is necessary even without indications, for the prevention of sexually transmitted diseases and pathologies in reproductive system. It should be borne in mind that these specialists are not included in the list of mandatory visits, and the examination can only be carried out in the presence of the child’s parent.

Taking tests

In addition to visiting and consulting with specialized specialists, to obtain a child’s medical card, it is necessary to undergo a number of tests. As a rule, these are standard studies:

1. Blood and urine for general analysis.
2. Feces for worm eggs and other protozoan organisms.

As a rule, research results are provided a few days after delivery. This depends on the workload of the outpatient laboratory. After receiving all the test sheets, a second visit to the pediatrician is required to draw up a card. After this, it must be signed by the chief physician of the clinic. The document is provided to the kindergarten at the request of the administration preschool. A sample of a child's medical record is presented below.

It is considered optimal to give it a month before the child is expected to attend kindergarten. The certificate must be submitted to the school before the first of September, otherwise the child may not be allowed to attend classes. Thus, it is necessary to take into account the time it takes to issue a card in order to provide it in a timely manner at the place of request.

The child’s medical record 026/у is signed by the chief physician medical institution only if all tests have been passed.

How to properly prepare for tests?

To avoid having to repeat analyzes due to unreliable data, it is important to follow certain recommendations when preparing for them. These standard tips include:

1. Urine must be collected in special sterile disposable containers. Before collection, you need to carry out hygiene of the genitals and blot them with a towel, and then collect the mid-morning portion.
2. Blood sampling should take place in the morning on an empty stomach. The analysis is carried out by piercing the finger with a special scarifier. Some parents prefer to purchase this needle themselves at the pharmacy.
3. Feces are also collected in plastic disposable containers, which are sold in every pharmacy.

Documents for registration

When the commission for issuing a child’s medical card for kindergarten, form 026/u, takes place at the clinic at the place of residence, only the child’s insurance policy is required. Specialists will be able to find all the necessary information in the child’s development card stored in the clinic, including birth data and vaccination card. If you choose a private clinic, you will need to provide a package of documents including:

Data on the card

The child's medical card form for the kindergarten is filled out by a nurse or pediatrician. On front side The document contains the following information:

1. Last name, first name, patronymic of the child.
2. Date of Birth.
3. Place of permanent or temporary registration.
4. Parents' details, including full name, place of work and telephone number.
5. Vaccinations performed and reactions to them.
6. Allergy (if any).

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 card and makes a decision on whether the child can attend the kindergarten under general conditions.

How much does it cost to obtain a child’s medical card for kindergarten?

Inspection options and costs

A medical examination is carried out free of charge at the children's clinic at your place of residence. This process is quite lengthy, sometimes taking more than a week, which is due to a discrepancy between the schedules of local specialists. Also, testing in public clinics takes quite a lot of time. 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 undergoing a medical examination directly at educational institution. It's also free and obviously convenient for both the child and the parents.

It is possible to obtain 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 You can receive it the very next day after your application. With this option, it is possible to see specialists even within one hour. However, you will have to pay a lot for such a high speed of service, since the price will include consultations with 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 comprehensive examination behind 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 in the future for the necessary consultation. The purpose of undergoing a medical examination is not only and not so much to draw up a card, but also to prevent diseases and pathologies.

We reviewed the child’s medical record form 026/у.

Two people told me a completely mythical story that they were able to obtain a medical card for a kindergarten in one day. They say that not for money, in an ordinary city clinic. For me, receiving form No. 026/u-2000 legally without bribes took three weeks. Having completed the registration procedure the other day, I want to tell you the details while emotions and negativity are still fresh.

So, you have decided to send your child to kindergarten (short-term or full-day). After receiving the consent of the head of the kindergarten, you are faced with the task bring a medical card for the child, with an examination by ALL (or almost all) specialists in the clinic, with the signature of the local pediatrician and the head of the preschool department of the clinic.

Where to begin?

Come for an appointment with your local pediatrician WITHOUT child. You can even approach the nurse (if the nurse is experienced and sane). They will create a medical card for the kindergarten and give it to you. This is a separate thin book in A4 format - form No. 026/у-2000(see photo).

With this form you will visit all doctors. Each specialist must set his own STAMP/DIAGNOSIS/NUMBER/SIGNATURE on this map.

Also, your local pediatrician should give you directions for tests ( general blood and urine, and).

Plus, the pediatrician will tell you which specialists the child needs to see.. In our case these were:

– orthopedist,
– neurologist,
– ECG (after it is ready – cardiologist),
– ophthalmologist,
– ENT (= otolaryngologist),
- surgeon,
- room healthy child(KZD),
– dentist (we have this in a separate clinic),
– speech therapist

With this entire list, you go to the reception desk and make an appointment with all the specialists. You can try to bypass all the doctors on baby's day (if the child is under 3 years old), but there are incredible crowds in our clinic on baby's day, so I preferred to go by appointment - although there was a queue, it was smaller.

My attempt to make an appointment with all the doctors for one day was a fiasco - this doctor was on vacation, the second one had not seen him since the morning, the third one had a medical examination. As a result, the visit to specialists was divided into 2 days.- the first time after 8 days in the morning (to get tested at the same time), the second time - a couple of days later in the evening. Separately, it was necessary to make an appointment with a dentist at a children's dental clinic.

The ECG took the longest to do– I was able to make an appointment with a doctor only after 10 days, we waited another week for the cardiologist to decipher it.

I don’t need to tell you how stuffy it is in the clinic. Dress your child as lightly as possible, take with you a change of shoes, summer T-shirts, a drink and a light snack! Because spending 3-4 hours in stuffy recreation is difficult even for an adult, not to mention restless running small children.

When you have visited all the specialists, you again need to go to your local pediatrician (or nurse) with your child. The doctor examines the child, weighs him, measures his height, looks at his throat, listens, etc. The nurse enters test results, information about parents, vaccinations, and the child’s current height and weight into the card.

By the way, if you haven’t received all your vaccinations on time, you will be forced to take one vaccination (the next one on the schedule) right now, or write a refusal to be vaccinated.

After the nurse has filled out form No. 026/у, you submit it for signature by the head of the preschool department of the clinic. This is another 1-2 days. Then, with the signature of the head, you go back to the pediatrician (without the child) and receive a certificate that the child is healthy.

As a result, I brought 3 documents to kindergarten:

– medical card for the child, form No. 026/у-2000
– vaccination card (issued by the manager)
- a certificate from a pediatrician.

Ugh. I have friends who chose to officially pay for a medical card for a kindergarten to commercial children's clinics, and I understand why they did so.

The price for such a service in Moscow ranges from 2,000 to 5,000 rubles(depending on the steepness of the clinic). Processing time 1-2 days :)

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Sometimes a patient wants to receive his medical card from the clinic. The desire is understandable and even quite legitimate - everyone has the right not only to health care, but also to receive information about the state of their health. However, in practice, patients often have problems obtaining a medical card - the receptionist refuses to issue it, sending patients to read the law.

In fact, misunderstandings between patients and health care providers on this issue often arise from ignorance or misinterpretation of the law.

Let's figure it out who has what rights and responsibilities if the patient wishes to receive his medical card in his hands. This also applies to cases where the child’s parent wants to receive a medical card.

So, in accordance with Part 5 of Art. 22 of the Law of November 21, 2011 No. 323-FZ “On the fundamentals of protecting the health of citizens in Russian Federation" the patient or his legal representative has the right on the basis of a written application, receive information reflecting the state of health medical documents, their copies and extracts from medical documents.

As can be seen from the text of this paragraph of the law, the patient has the right not only to receive a copy or extract from medical document, but also the medical documents themselves. This means that all the arguments of the clinic employees (doctors, nurses, receptionists and others) that this law allows patients to rely only on receiving a copy of the medical record or an extract from it are null and void. And no arguments from medical workers about the inadmissibility of disclosure medical confidentiality, and what is even more stupid - that the medical institution is supposedly the owner of the medical card cannot be considered legal and justifying their illegal refusal to issue documents to patients.

This clause of the law clearly gives the patient the right to receive medical documents, which include a medical record. The law does not establish any restrictions or conditions for the exercise of this right. Therefore, even if some letters, instructions and other documents are issued at the departmental level that restrict the right of patients to receive original medical documents, all of them are illegal.

What should a patient do if he wants to officially receive a medical card from the clinic?

The patient must contact the medical institution in writing. Moreover, it is important to write two copies of such an application - one is given to the doctor or receptionist, and on the second copy the recipient of such an application must put a mark of receipt indicating the date, time, signature and transcript of the signature. Moreover, patients can be advised to check whether their application is recorded in the medical institution's incoming correspondence log.

Only such an official statement can guarantee the safety of the nerves and time of the patient who wants to receive a medical card in his hands in cases of inadequately disposed medical workers.

Unfortunately, there is a lot of information on the Internet that patients are denied a medical card, some even use cunning to “get” their medical cards, and this information is followed by many comments and stories with conclusions that this is how it should be , because the medical card is supposedly the property of the medical institution.

But in reality there is no question of whose property the medical record is. The question is about the implementation of the rights of citizens established by federal law, and not some internal instructions convenient for doctors.

It is worth noting that in most cases it may be sufficient for the patient copies of medical records or extracts from it.

For example, this may be necessary when the card is needed for consultation with a specialist in another medical institution. But, as practice shows, patients often find notes in their medical records, including those about doctor appointments that did not happen; moreover, medical records sometimes get lost within the walls of a medical institution, or sheets that are important for the patient “miraculously” disappear from them. All these violations contribute to the increasingly frequent desire of patients to keep their medical records and the medical records of their children at home, and, if necessary, provide them to doctors.

Therefore, it is worth knowing and understanding that this is guaranteed by federal law. patients' right, and there is not a single law prohibiting them from receiving original medical documents in their hands.

As for copies of medical documents (including medical records), it is important to note that in order for these to be not just copies, but documents, it is necessary that they be duly certified medical institution.

This means that all sheets of copies of medical documents must be numbered and stitched into a single block. Ideally, on each page of such a copy there should be the seal of the organization and the mark “Copy is correct” with the date of certification of the copy and the signature of an authorized person. The bound copy of the medical record is also certified on the bound spine with the seal and signature of an authorized person, his full name, the date of certification of the copy, and the total number of sheets are indicated.

The child's legal representatives - parents, adoptive parents, guardians and trustees - have the right to receive a medical card and other documents of the child. It is clear that in order to prove that a child’s medical card is not requested by a stranger, it is necessary to present documents confirming that the applicant is the legal representative of the child. So for parents, a passport with a mark about the registered child is quite enough.

Considering the above, it can be argued that the refusal to hand over a medical card to the patient or his legal representative is a direct violation of the law. This means that such a refusal can be appealed to judicial procedure, file a complaint with the health authority of the constituent entity of the Russian Federation ( regional Ministry health care), as well as to the prosecutor's office.

And lastly: within what period should medical documents or their copies, extracts be submitted at the request of the patient or his legal representative?

Taking into account the general procedure for considering citizens’ appeals, we can talk about a 30-day period. But in general, a specific period in in this case the law does not establish, and therefore documents must be provided within a reasonable time. 3 days in such cases can be considered more than sufficient time to satisfy the patient’s legitimate request. But there are also exceptional cases, medical documents are urgently needed to provide emergency or urgent care. medical care. Moreover, the patient generally has the right to indicate in his application a specific period within which he needs these documents. And then they are obliged to issue documents to him exactly within this period.

And even if there is a need to immediately receive a medical card, and this is indicated in the patient’s application with justification for the need - incl. for an urgent visit to a doctor in another clinic, then legal grounds There are simply no options to refuse such a patient.

More precisely, it is possible to refuse only if the medical record is not physically available in the medical institution due to its earlier demand by law enforcement agencies, an insurance medical organization, a compulsory health insurance fund or another body that has the right to make official requests for the issuance of original medical documentation.

By the way, in 2017 the Prosecutor's Office Perm region sent documents to the court to bring the chief physician to administrative responsibility for refusing to provide copies of documents from the medical record.

New information for 2018:

In this regard, the concerns of patients who want to store their medical records at home are understandable.

If you have a problem in obtaining your documents from a medical institution and you need help in drawing up an application for receiving your medical card or a copy of it from the clinic, please report this at e-mail: info@site

Every person has probably been to a medical institution, where one of the most important documents is the medical record of an outpatient. Neither the doctor nor the patient can do without it.

Why is an outpatient card needed?

How correctly this document is filled out may determine the fate of the patient in the framework of a possible criminal or civil case being investigated in relation to him.

An extract from the outpatient card is required:
⦁ when carrying out forensic medical examinations;
⦁ to make payments for the provision of medical care under compulsory medical insurance contracts;
⦁ to conduct medical and economic examinations to monitor the quality of medical services provided.

What is a patient's outpatient card?

In approved in November 2011 Federal Law No. 323, which regulates the health of our compatriots, there is no such thing as medical documentation.

The medical encyclopedia includes a system of documents that have a prescribed form, the purpose of which is to register information about measures for prevention, treatment, diagnosis and sanitary hygiene.

Medical documentation can be accounting, reporting and accounting. The outpatient medical record falls into the first category. It describes the diagnoses Current state patient, recommendations for treatment.

Introduction of the updated form

Order of the Russian Ministry of Health No. 834 of December 2014 approved updated unified forms of documentation used by outpatient medical institutions. It also states how they are filled out.

This is a significant step towards creating a medical record electronic form, since the introduction of uniform standards in the execution of records ensures mutual continuity among medical institutions.

In particular, form No. 025/u - “Medical record of an outpatient patient” has been developed, and it is described in detail how it should be filled out. In addition, a sample patient coupon with the appropriate filling procedure has been approved.

The above-mentioned order gave this card the status of the main registration medical document of an institution providing medical care for the adult population using outpatient conditions.

How is it different from the old form?

In the new accounting form, the information content has been significantly increased, and the positions to be filled out have been specified in more detail. In the previous version, the doctor could make notes at his own discretion; now they are unified.

The following information was required to be entered:
⦁ about consultations with narrow medical specialists and the head of the department;
⦁ about the result of the meeting of the All-Conference Committee;
⦁ about taking x-rays;
⦁ on making a diagnosis according to the 10th International Qualification of Diseases.

For each specialized medical institution or their specialized structural area in dentistry, oncology, dermatology, psychology, orthodontics, psychiatry and narcology, its own outpatient card has been developed. Form No. 043-1/u, for example, is filled out for orthodontic patients, No. 030/u is intended for a control card for dispensary observation.

Form No. 030-1/u-02 is issued for persons suffering from psychiatric diseases and drug addiction. It was approved in Order of the Ministry of Health of the Russian Federation of 2002 No. 420.

How is it filled out?

During a person’s very first visit to the clinic, the receptionist fills in the data on title page. But a patient’s outpatient card can only be filled out by doctors.

If the patient belongs to the category of federal beneficiaries, an “L” is indicated next to the card number. The doctor must make an appropriate record of each patient’s visit to the clinic.

Outpatient card reflects:
⦁ how the disease progresses;
⦁ what diagnostic and therapeutic measures are consistently carried out by the attending physician.

The entry is made carefully, in Russian, in the appropriate section without any abbreviations. If it is necessary to correct something, this is done immediately after the mistake is made and must be certified by a doctor’s signature.
It is acceptable to use Latin to write the names of medications.

The health worker fills out the first sheet in the registry according to the data from the patient’s identification documents. Workplace and position graphs are recorded according to the patient’s words. The form contains recommendations for completing each section.

Filling principles

When filling out an outpatient card, you should remember some basic principles.

It should chronological order be described:
⦁ in what condition the patient came to see the doctor;
⦁ what diagnostic and therapeutic procedures were performed;
⦁ treatment results;
⦁ circumstances of a physical, social and other nature that influence the patient during pathological changes in his well-being;
⦁ the nature of the recommendations given to the patient at the end of the examination and treatment process.

The doctor must comply with all legal aspects when filling out the form.

The outpatient card consists of forms on which long-term and operational information is recorded.

Long-term information contained on front-adhesive sheets includes:
⦁ information copied from an identity document;
⦁ blood group with Rh factor;
⦁ information about transferred infectious diseases And allergic reactions;
⦁ final diagnoses;
⦁ results of preventive examinations;
⦁ list of prescribed narcotic drugs.

Operational information is recorded on inserts where the results of the initial visit and secondary visits to the local therapist, specialized doctors, and consultations with the head of the department are recorded.

Extract from outpatient card

An extract is a medical certificate of health in form 027/y, which belongs to the second group of medical records documentation. It contains information about illnesses suffered during outpatient treatment.

Its purpose, like all the documentation of this group, is to quickly exchange data on the health of patients, which helps to connect the individual stages of sanitary-preventive and therapeutic measures.

The extract can be provided by the patient to the employer to inform about the completion of outpatient treatment. It is not subject to payment, but is submitted together with the sick leave certificate, if the latter is issued for more than a month.

This document allows you to be exempt from classes in educational institutions.

The extract contains information about the patient, indicating the medical policy number, listing his complaints, symptoms of the disease, the results of medical examinations and examinations, as well as the primary diagnosis.

All information must fully correspond to that contained in the outpatient card.

The extract can be used to prescribe further medical procedures.