Analysis of medical records in a specialized osteopathic clinic in Moscow

Lidia V. Tumbinskaya , Olga V. Yashchina , Marina Yu. Gerasimenko

Russian Journal of Physiotherapy, Balneology and Rehabilitation ›› 2019, Vol. 18 ›› Issue (1) : 28 -32.

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Russian Journal of Physiotherapy, Balneology and Rehabilitation ›› 2019, Vol. 18 ›› Issue (1) : 28 -32. DOI: 10.17816/1681-3456-2019-18-1-28-32
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Analysis of medical records in a specialized osteopathic clinic in Moscow

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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.

Keywords

medical documentation / organization of osteopathic care / quality of medical care / licensing

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Lidia V. Tumbinskaya, Olga V. Yashchina, Marina Yu. Gerasimenko. Analysis of medical records in a specialized osteopathic clinic in Moscow. Russian Journal of Physiotherapy, Balneology and Rehabilitation, 2019, 18(1): 28-32 DOI:10.17816/1681-3456-2019-18-1-28-32

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References

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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).

[2]

Медицинская документация в частных клиниках: правовой аспект. URL: https://www.zdrav.ru/articles/4293656616-qqess8-meditsinskaya-dokumentatsiya-vchastnyh-klinikah

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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).

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[5]

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).

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Приказ Минздрава России от 15.12.2014 № 834н «Об утверждении унифицированных форм медицинской документации, используемых в медицинских организациях, оказывающих медицинскую помощь в амбулаторных условиях, и порядков по их заполнению». URL: https://minzdrav.gov.ru/documents/8337-prikaz-ministerstva-zdravoohraneniya-rossiyskoy-federatsii-ot-15-dekabrya-2014-g-834n-ob-ut.

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