You will need
- form reference form 095;
- form reference form 027.
Help shape 095 fills the doctor or therapist, depending on patient age. It is issued after the end of the disease at the time of discharge to study.
On each filled certificate shall bear a serial number. Then highlighted the desired value of the printed in the entry form. It shows the student what institution issued the certificate. Put legible date of issue, the abbreviated name of the educational institution, such as Altai state medical University, indicate the name of the patient and date of birth (day, month, year).
Next is written the diagnosis on the basis that he was exempt from training, for example, the flu. Emphasizes the presence or absence of contact with infectious patients.
In the respective graphs indicate date of illness, date of physician visit, date of extending help and end date of the disease. Stamped number, which you want to begin classes.
Put the stamp of the clinic, the full name of the attending physician, his signature and personal seal.
If the illness lasts more than 14 days, in addition to the application for the certificate of the certificate 095 027. It is, in fact, an extract from the medical record or history of the disease. It includes all the patient details, home address, date of birth, date of referral to inpatient treatment, discharge from hospital, the diagnosis and complete description of the disease. Help put the seal of a medical institution which has issued the document, the signature and stamp of doctor, doctor from the hospital, the signature and seal of the chief physician.
Help form 027 issued for 75 days. If the disease persists or progresses, gave serious complications, the issue of disability.
Disability sets medical-social expert Commission on the basis of all the submitted surveys, extracts from the history of the disease and General condition of the patient.
Advice 2: How to fill out a medical history
Correctly completed history of illness affects the speed of operation of the medical personnel and the treatment outcome. You must actively question the patient and record these conversations in the form of the history of the disease.
Specify on the cover sheet surname, name, patronymic of patient, date of birth, home address, place of employment, date of admission to medical institution and admission diagnosis. Write clearly when filling in the history of the disease from the hands.
In the section "passport part" enter the surname, name, patronymic of patient, age, date of admission and admission diagnosis. In the treatment process, complete this section clinical and final diagnoses, and discharge date. When writing a diagnosis, highlight the main and concomitant diseases, their complications.
List all the patient's complaints in the section "Application for admission", detail them. If the patient is taciturn, alone ask questions.
In the "disease History" describe where the patient first felt ill, as of this moment, before getting to the hospital changed his condition.
In "the History of life describe how the patient grew and developed in childhood, which the disease and operations have moved if he had allergies. If the patient has bad habits, this do record in this section history of the disease.
The sheet "Objective examination" complete data examination of the patient. Describe all the changes that are found.
Put a diagnosis on the basis of complaints, anamnesis and data of objective inspection in the section "Preliminary diagnosis".
Assign treatment, and record it in the "list of appointments". Drug names write in a column on the left side of the page on the Latin language in the form of recipes. Research, which must pass the patient record to the right of the recipes.
Every day in "Diary of observation" describe the patient's complaints during the inspection, what has changed in his condition
Before discharge write a discharge summary, which briefly list the data of all sections and the result of treatment.