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Структура медицинской карты пациента, получающего медицинскую помощь в стационарных условиях и в условиях дневного стационара

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Медицинская карта пациента, получающего медицинскую помощь в стационарных условиях

Оглавление

Введение

Структура медицинской карты пациента, получающего медицинскую помощь в стационарных условиях и в условиях дневного стационара -

Сведения о пациенте (приложение 6)

Направление

Квитанция на прием личных вещей пациентов

Листы информирования пациента

Записи о первичной сортировке пациента

Протокол первичного осмотра пациента (приложение 7)

Предварительный диагноз

План обследования

План лечения

Назначения

Обоснование клинического диагноза

Клинический диагноз

Срок установления клинического диагноза

Лист назначений и их выполнение (приложение 16)

Медицинские вмешательства — оборотная сторона листа назначений

Лист регистрации показателей жизненно важных функций организма (приложение 19)

Результаты лабораторных исследований

Протоколы рентгенологических исследований

Лист учета лучевой нагрузки (приложение 20)

Протоколы ультразвуковых исследований

Протоколы эндоскопических исследований

Протоколы функциональных исследований

Протокол трансфузии донорской крови и (или) ее компонентов (приложение 17)

Лист регистрации трансфузий (переливания) донорской крови и (или) ее компонентов (приложение 18)

Осмотры (приложение 8)

Записи лечащего врача

Дневники наблюдения за пациентом

Предоперационный эпикриз (приложение 10)

Предоперационный осмотр врачом анестезиологом-реаниматологом (приложение 9)

Протокол оперативного вмешательства (приложение 11)

Протокол анестезиологического пособия (приложение 12)

Карта проведения анестезиологического пособия (приложение 13)

Лабораторный мониторинг проведения анестезиологического пособия, интенсивной терапии (приложение 14)

Карта проведения реанимации и интенсивной терапии (приложение 15)

Этапный эпикриз

Передаточный эпикриз

Обход заведующего отделением

Обход главного врача (заместителя главного врача)

Консилиум врачей

Эпикриз на врачебную комиссию

Протокол сердечно-легочной реанимации

Протокол установления смерти человека (приложение 22)

Выписной (переводной) эпикриз (приложение 21)

Выписка из медицинской карты стационарного больного злокачественным новообразованием (форма 027-1/у)

Посмертный эпикриз (приложение 23)

Копия протокола патологоанатомического вскрытия или копия заявления об отказе в проведении патологоанатомического вскрытия

Дополнительная информация

Чек-лист внутреннего контроля качества медицинской помощи (приложение 24)

Приложения +

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Литература