Analysis of medical records in a specialized osteopathic clinic in Moscow
- Authors: Tumbinskaya L.V.1, Yashchina O.V.1, Gerasimenko M.Y.2
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Affiliations:
- Ostmed LLC
- Russian Medical Academy of Continuous Professional Education, Ministry of Health of the Russian Federation
- Issue: Vol 18, No 1 (2019)
- Pages: 28-32
- Section: Original studies
- URL: https://journals.rcsi.science/1681-3456/article/view/62434
- DOI: https://doi.org/10.17816/1681-3456-2019-18-1-28-32
- ID: 62434
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Abstract
Introduction. In clinics, hospitals, public and private hospitals, it is necessary to ensure that documentation meets all the requirements of the industry regulator. Registration, maintenance, systematization, storage of medical documentation is a specific and difficult task, it serves as a means of proving the conduct of medical, diagnostic and other specialized procedures. Medical documents serve as a tool for monitoring the quality of medical services provided, confirming the fact of assistance and revealing its essence.
The goal is to conduct internal quality control of medical documentation and develop a set of measures to improve quality control of medical care.
Methods. The research uses statistical methods of data processing (calculation of shares, average) and analysis of literature data .
Conclusion. As one of the main indicators of the effectiveness of the chief physician, it is necessary to consider quality control of medical documentation, the most complete registration of it by specialists of the clinic and regular training of clinicians.
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##article.viewOnOriginalSite##About the authors
Lidia V. Tumbinskaya
Ostmed LLC
Email: mgerasimenko@list.ru
ORCID iD: 0000-0001-6648-3322
PhD
Russian Federation, MoscowOlga V. Yashchina
Ostmed LLC
Email: mgerasimenko@list.ru
главный врач «Остеомед»
Russian Federation, MoscowMarina Yu. Gerasimenko
Russian Medical Academy of Continuous Professional Education, Ministry of Health of the Russian Federation
Author for correspondence.
Email: mgerasimenko@list.ru
DSc, Prof.
Russian Federation, MoscowReferences
- Medicinskaja dokumentacija v chastnyh klinikah: pravovoj aspekt [Medical documentation in private clinics: legal aspect]. URL: https://www.zdrav.ru/articles/4293656616-qqess8-meditsinskaya-dokumentatsiya-vchastnyh-klinikah. (In Russ).
- Federalnyj zakon 323-FZ ot 21-11-2011 “Ob osnovah ohrany zdorovya grazhdan v rossijskoj federacii s izmeneniyami vstupivshimi v silu s 10-08-2017 [Federal law No. 323-FZ of 21.11.2011 “On the basics of public health protection in the Russian Federation” with amendments that came into force on 10.08.2017]. URL: https://minzdrav.gov.ru/documents/7025. (In Russ).
- Prikaz Minzdrava Rossii ot 15-12-2014 834n “Ob utverzhdenii unificirovannyh form medicinskoj dokumentacii ispolzuemyh v medicinskih organizaciyah okazyvayushchih medicinskuyu pomoshch v ambulatornyh usloviyah i poryadkov po ih zapolneniyu” [The Ministry of Health of the Russian Federation’s Order dated 15.12.2014 No. 834n “On approval of unified forms of medical documentation used in medical organizations that provide medical care in outpatient settings, and the procedures for filling them out”]. URL: https://minzdrav.gov.ru/documents/8337-prikaz-ministerstva-zdravoohraneniya-rossiyskoy-federatsii-ot-15-dekabrya-2014-g-834n-ob-ut. (In Russ).