REGISTRATION MEDICAL CASE HISTORY
The clinical history of the disease is written from admission and is maintained until patient's discharge with the requirements of the accuracy of the records. The pages of this medical document are illed in in clear handwriting or printed out on a printer in the presence of an electronic form. On the title page, the date and time of admission are entered, upon discharge / transfer - the date of completion of the hospital stay and the number of bed-days spent.
The irst and second pages of the title page are drawn up in accordance with the approved form 003/y.
The patient's passport data is recorded - full name, date of birth and age with indication of full years and months of life, home address with indication of phone number.
Features of the medical history of a pediatric patient
1. Pediatric medical history differs from the medical history of an adult in that on the title page, in the column "place of work", the child's visit to a preschool or school institution is noted with an indication of his address and number, and also the full name of the parents or the legal representative of the child (guardian, etc.) and their telephone number are recorded for the possibility of communication if necessary.
2. Enter information about the referral establishment (ambulance station, out-patient clinic, maternity hospital, infant home, etc.), as well as referral diagnosis.
3. On the second page of the document, the date of opening the child care sick leave for parents/guardian during their hospitalization for caring for the child, information about the epidemiological situation is recorded.
4. Pre-assessment of the patient in the hospital is carried out by the doctor of the admission ward, and, if necessary, by a specialist (surgeon, neurologist, traumatologist, etc). They make a detailed record of complaints, anamnesis of the disease and life, the results of an physical examination and make judgments about referral diagnosis, plan of examination and treatment, regimen.