Electronic medical record main functions. Patients are not allowed to look at their cards when ordered "from above"

References to medical secrecy and legal requirements do not apply to polyclinic patients today. As the portal browser found out, in addition to references to regulations, doctors have other reasons for refusing to issue an outpatient card.

Silent war going on with varying degrees of success

Medical records are the main primary accounting documents for outpatient care. This is stated in the order of the Ministry of Health of the Republic of Belarus dated August 30, 2007 No. 710 "On approval of the forms of primary medical documentation in outpatient organizations." They can be different - in contrast to the profile of the institution:

• form No. 025 / y-07 "Medical record of an outpatient";
• form No. 065 / y-07 "Medical record of an outpatient with sexually transmitted infections";
• form No. 065-1 / y-07 "Medical record of a patient with a fungal disease, scabies";
• form No. 065-2 / y-07 "Medical record of an outpatient with a skin disease."

The outpatient medical record is the main medical document of the patient and is filled out for a person at the first request for medical care.

And this is where the problems in the relationship between doctors and patients begin. Doctors claim that the card is the property of a medical organization, and handing it over to patients is prohibited. Moreover, the entries in this document are classified as confidential information and are not subject to disclosure.

But, on the other hand, patients have a quite reasonable question: “Why is the data on the state of MY health the property of the clinic?” Portal some time ago with a request to judge people who are on opposite sides of the door of the doctor's office. And I heard that a medical outpatient card is a document that is filled out and maintained by people with special education, using professional terminology and acceptable abbreviations. And these cards "are kept not for the patient, but for the attending physician and his medical colleagues - they reflect the medical work and accumulate information about the patient."

At the same time, inquisitive patients found out that back in 1998, the Ministry of Health of the Republic of Belarus issued order No. 384, which prohibited the storage of outpatient cards in the hands of patients . But! The document has long lost its force due to the adoption of the Decree of the Ministry of Health of the Republic of Belarus dated November 20, 2007 No. 119.

As the portal browser found out, there is another curious document: a letter from the Ministry of Health of Belarus dated July 31, 2009, which appeared in response to the proposal of the Prosecutor General's Office to eliminate violations of health legislation in terms of familiarizing citizens with information about their own health.

The letter notes that in accordance with Article 46 of the Law of the Republic of Belarus "On Health Care", information about the patient's health status is provided by the attending physician to the patient or persons specified in part 2 of Article 18 of this law:

• for minors - one of the parents, adoptive parents, guardians, trustees;
• for persons recognized in the prescribed manner as incapacitated - guardians;
• for persons who, due to health reasons, are not capable of making an informed decision - a spouse or one of their close relatives (parents, adult children, siblings, grandchildren, grandfather (grandmother)).

Information about the state of health of the patient is presented by the attending physician "in a form that meets the requirements of medical ethics and deontology (the teachings on the problems of morality and ethics - IF) and accessible to the understanding of a person who does not have special knowledge in the field of health care.

Further, the document states that, if necessary, the patient or his representative (see the list above), health organizations issue extracts from medical records, certificates and other documents containing information about the state of health.

The Ministry of Health also reminds that the healthcare organization ensures the storage of medical records in accordance with the requirements for maintaining medical secrecy. And medical secrecy, according to Article 46 of the Law of the Republic of Belarus "On Health Care", consists of:

• information about the fact that the patient applied for medical care and the state of his health;
• information about the presence of the disease, diagnosis, possible methods of providing medical care, the risks associated with medical intervention, as well as possible alternatives to the proposed medical intervention;
• other information, including personal information, obtained in the course of providing medical care to the patient, and in the event of death, information on the results of the postmortem examination.

Legal acquaintance - only in the presence of professionals

But what about patients who want, say, to make sure that the records made by medical professionals are correct? After all, disputes between doctors and patients are not uncommon. In the letter from the Ministry of Health mentioned above, there is a mention of a compromise. Let's have a quote.

"If necessary, the patient or his legal representative may familiarize himself with his medical outpatient (form No. 025 / y-07) or medical inpatient (form No. 003 / y-07) patient cards in a healthcare organization in the presence of medical workers."

Alexander Nesterov

Moscow State Medical and Dental University

Department of Ophthalmology

Head Chair: MD, Professor Takhchidi Hristo Periklovich.

Teacher: PhD Gadzhieva Nuria Sanievna.

Outpatient card

Clinical diagnosis: ou: Myopia of low severity. Esophoria.

5th year students of 26 groups

medical day faculty

Passport data

FULL NAME. sick

Age19 years old (10.02.1987).

Family statusUnmarried

Educationincomplete higher

Place of workMGMSU

Position5th year student of the Faculty of Medicine

LocationMoscow city

Complaints

Decreased distance visual acuity.

History of present illness

(Anamnesismorbi)

The above complaints appeared about 6 years old, when a decrease in visual acuity to the right to 0.7, to the left to 0.5 was first detected. visual acuity was corrected with spherical diverging lenses -0.5 (OD) and -0.75 (OS). The last time was observed by an ophthalmologist a year and a half ago - visual acuity without dynamics. In the last six months, he has noticed a deterioration in distance vision.

Life story

(Anamnesisvitae)

She grew and developed correctly, did not lag behind her peers, and there were no deviations from her health.

As a child, she had chickenpox, rubella, SARS. In 2002, an appendectomy.

The presence of allergic reactions denies.

Bad habits - denies.

Heredity: The mother has moderate myopia.

The present state of the patient

(Statuspraesens)

General condition of the patient:satisfactory

State of consciousness: clear

Skin and visible mucous membranes:

The skin is moderately moist, pale pink, without pathological changes. The mucous membranes are quite moist, there are no pathological changes, the vascular pattern is not pronounced.

Respiratory system:The shape of the chest is conical; chest type - normosthenic, both halves of the chest are symmetrical.Type of breathing - chest. Respiratory movements are symmetrical, auxiliary muscles are not involved in the act of breathing. The number of respiratory movements per minute is 16. The depth of breathing is average. Breathing rhythmic, nasal. Vesicular breathing is heard over the entire surface of the lungs during auscultation, there are no side breath sounds.

The cardiovascular system:Heart sounds are clear, rhythmic. During auscultation, the ratio of tones is not disturbed, there are no noises. Heart rate 80 bpm. BP 110/65 mmHg on both arms.

Digestive system:The tongue is pink, moderately moist, the papillary layer is normal, there is no plaque. The belly of the correct form, symmetrical, takes part in the act of breathing. Visible peristalsis of the stomach and intestines is not observed. There are no visible tumor-like and hernial protrusions. The abdomen is soft on palpation, painless in all departments. The lower border of the liver runs along the edge of the right costal arch. Physiological functions are normal.

urinary system:Difficulty urinating, the presence of involuntary urination, false urge to urinate, cramps, burning, pain during urination, frequent urination, no nighttime urination.Pasternatsky's symptom is negative on both sides.

Endocrine system: When examining the anterior surface of the neck, the thyroid gland is not enlarged in size, with approximate palpation, the surface of the gland is smooth, there are no nodes, painless. On examination, we observe a uniform distribution of the subcutaneous fat layer. Hair on the female type.

Neuropsychic sphere:Consciousness is clear, speech is intelligible. The patient is oriented in place, time and self. On the part of the motor and sensory spheres, no pathology was detected. Tendon reflexes without pathology.

Ophthalmic status

(Statusoculorum)

Visual acuity and refraction:

1. Subjectively (Sivtsev's table):OD0.1 - 0.2, correctedconcav sp. -1,5 D = 1,0;

OS0.1, correctedconcav sp. -1,75 D = 1,0

A) before atropinization:OD sp -1,5 D; OS sp -1,75 D

B) after atropinization:OD sp -1,25 D; OS sp -1,5 D

color perception(using Rabkin's polychromatic tables): Normal trichromacy.

The nature of vision(using four-point color test): binocular vision.

The position of the eyeballs in the orbit, their mobility:The position of the eyeball in the orbit is correct, the eyeball is of normal size, spherical shape, full range of motion, painless. Full mobility of the eyeballs in the orbit.

Definition of heterophoria: an indicative method using the Medox rod - esophoria (3 prism diopters).

palpebral fissure, eyelids:The palpebral fissures are the same on both sides, 10 mm wide. The skin of the eyelids is smooth, elastic, of normal color. The eyelids are mobile, eyelashes are located along the marginal edge, the growth of eyelashes is correct.The excretory ducts of the meibomian and sebaceous glands are not dilated.

Lacrimal apparatus:tearfulgland is not palpable.Dry eyes and pathological lacrimation are absent.The lacrimal points are moderately expressed, immersed in the lacrimallakes, tightly adjacent to the eyeball (visible when pulling the eyelid from the eyeapples). Detachable from the lacrimal openings with pressure on the projection areathere is no lacrimal sac. There is no pain on palpation of this area. The skin inthe area of ​​the projection of the lacrimal sac is not changed.

Conjunctiva of the eyelids, eyeball:The conjunctiva of the eyelids is pink, shiny, smooth, moist, no discharge. The conjunctiva of the eyeball is shiny, almost transparent, small vessels are visible.

Sclera:White, smooth. Eye injections - no.

Cornea:FROMspherical shape, transparent, smooth, shiny, mirror, size 10 * 11 mm. cornealthe reflex is alive, the sensitivity is preserved.

Front camera:Medium depth (approx. 3 mm), even, on both sidesexpressed equally, the anterior chamber is filled with a clear intraocular fluid.

Iris:ABOUTboth eyes are colored the same, dark brown, radially striated, the pattern is clear,the pigment border around the pupil is preserved. Pupils are located in the center, regular roundshapes, black, the same on both sides. Lively react to lightaccommodation and convergence.

Eyelash body:Palpation of the eyeball in the projection area of ​​the ciliary body is painless.

lens:Transparent, the position is correct.

vitreous body:The vitreous body is transparent.

Ocular fundus:The reflex from the fundus is red, uniform. The optic disc is pale pink in color, its boundaries are clear, andthere isshallow physiological excavation. The position of the vascular bundle is central,the course of the vessels is not changed. The ratio of the caliber of arteries and veins is 2:3.In the area of ​​the macula and on the periphery of the retina, pathological changes are not determined.

Intraocular pressure:Palpation within normal limits (Tn).

Fields of view:

Clinical diagnosis: ou: myopia of low severity. Esophoria (3 prism diopters).

In domestic medicine, electronic technologies continue to be introduced, in particular, this is an automated workplace for a doctor (arm polyclinic), as well as electronic medical records (EMC). I must say that this process is quite long in time, as it encounters numerous obstacles on its way, namely:

• the need to spend on the purchase of the necessary equipment, the development of the necessary software,
• training doctors to work with information technology. In fact, this training goes like this: here is a program for you, study 😉
• the need to store medical records for a long time.
• protection of documentation from hacker attacks.

There must be a sufficient number of computers.

You can get acquainted with the detailed research of the site gosbook.ru on the topic of the legality of using electronic medical records, the pitfalls that these innovations are fraught with.

Program for maintaining an electronic medical record

To date, EHR is conducted in a multifunctional program designed to collect statistical data - "Automated doctor's place", it is also called "". You can see her work at the link. In the AWP polyclinic, visits of patients are recorded, coupons are issued, diagnoses are recorded in encrypted form, and the services provided by the doctor are filled in. The ARM Polyclinic program stores personal data of patients. It is also possible to maintain an electronic medical record.

How to maintain an electronic medical record

Using the example of the Doctor Workstation program, I will show you how to fill out an electronic medical record, how to create templates and use them, how to print documentation.

In the "Patient Reception" section, click on any patient's full name and the following window will open:

This window can be schematically divided into 3 sections - the upper one, where complaints, anamnesis, objective status data are entered, and the performed techniques are automatically displayed by the program. Opposite this section there is a button "Templates". By clicking on it, you can create templates for complaints, anamnesis, objective status, and also use them.

The middle section is for established diagnoses. Diagnoses are displayed automatically by the program after their introduction by the ICD-10 code. However, you can supplement them, clarify the side of the lesion, the number of the tooth in accordance with the two-digit classification (see article). Opposite the middle section there is also a "Templates" button for using diagnosis templates.

The bottom section is for prescriptions, treatments, and recommendations. You can fill it in manually, for which you first need to click on the “+” icon or use the appropriate templates (opposite the treatment window).

How to set up EHR templates

I will show how you can set up templates for an electronic medical record using the example of templates for the treatment of dental diseases.

1. Previously, you can create treatment templates in notepad and save in *txt format. This step will make it easier for you to install templates on several different computers. If you have one working computer or if you are not embarrassed by the monotonous work, then you can skip this step.
   Below you will be offered template options for dental diseases. If you work in another branch of medicine, then you can read them to get an idea of ​​how to create templates.
2. Click on the "Templates" button in the lower section of the window designed to fill in the electronic medical record of the "ARM Polyclinic" program.
   
   
3. Adding a new template. First, expand the menu by clicking on the double arrow in the upper right corner of the window, then click on the "Add New" button
   
   
4. Fill in the name of the template (name it for your convenience, it will be available only to you) and write the text of the template below.
   
   
   If you created a txt file with template text, then you can load it into the program. To do this, use the "From file" button and select a template from the folder on your computer. Save the changes (the "Save" button).
5. How to use the created templates. In the Recommendation Templates window, after you have created your templates, you see a list of clichés. Click on any so that the arrow is highlighted in red. In the lower field you will see the text of the template. Click on the "Insert All" button, and the text of your template will be embedded in the desired EHR field. All you have to do is make the necessary adjustments.
6. Printing a completed case for a paper card. At the bottom of the same window, you will see a "Print" button. click on it, then on "Conclusion"
   
   

Examples of treatment patterns and objective status of dental patients at a therapeutic appointment

You can view and download the templates

In the work of a polyclinic doctor, the completeness and correctness of filling out the patient's outpatient card is of great importance, since it is it that serves as evidence in court when considering both civil and criminal cases, is the basis for conducting a forensic medical examination, serves as the basis for payment for medical services provided; calculation of payment, medical and economic examination, medical and economic control and examination of the quality of medical care under the contract of compulsory medical insurance.

Federal Law No. 323-FZ of November 21, 2011 “On the Basics of Protecting the Health of Citizens in the Russian Federation” does not contain the concept of medical documentation. In the Medical Encyclopedia, medical documentation is understood as a system of documents of the established form, intended for registration of data on medical, diagnostic, preventive, sanitary and hygienic and other measures, as well as for their generalization and analysis. There are medical documentation accounting and reporting, as well as accounting and settlement. The medical records contain a description of the patient's condition, his diagnosis, treatment and diagnostic recommendations. The outpatient card is, perhaps, the central primary accounting medical document. Additional interesting information is reflected in our other articles: "Medical records: status and types" and "Accounting, storage and execution of medical records".

New form of outpatient card

In March 2015, a new order came into force that regulates the unified forms of medical documentation used in outpatient settings and the procedure for filling them out. This is a significant step towards an electronic medical record, as uniform standards for the design of records are being laid down, which will ensure continuity between medical organizations. We are talking about the new Order of the Ministry of Health of Russia dated December 15, 2014 No. 834n “On approval of unified forms of medical documentation used on an outpatient basis and the procedure for filling them out”, which approved: Form No. 025 / y “Medical record of a patient receiving medical care on an outpatient basis” , the procedure for filling out the registration form No. 025 / y “Medical record of a patient receiving medical care on an outpatient basis”, as well as a coupon for a patient receiving outpatient care and the procedure for filling it out. This document defines that "Account Form No. 025 / y" Medical record of a patient receiving medical care on an outpatient basis "(hereinafter referred to as the Card) is the main accounting medical document of a medical organization (other organization) providing medical care on an outpatient basis to the adult population (hereinafter referred to as the medical organization). When compared with the currently canceled registration form approved by the Order of the Ministry of Health and Social Development of the Russian Federation dated November 22, 2004 No. 255 “On the procedure for providing primary health care to citizens entitled to receive a set of social services (with amendments and additions) ”, the form of the map has changed significantly, it has become more meaningful, the points and sub-points that need to be filled in have been specified. Previously, the form of many entries was left to the physician's discretion. In addition, it became mandatory to fill out, in the prescribed manner, the consultation of specialist doctors, the head of the department, information about the meeting of the medical commission, accounting for X-ray exposure, making a diagnosis according to ICD-10, and the procedure for registering patient monitoring.

In specialized medical organizations or their structural subdivisions by profiles: oncology, phthisiology, psychiatry, psychiatry-narcology, dermatology, dentistry and orthodontics, and a number of others, they fill out their accounting forms of outpatient cards. For example: form No. 043-1 / y “Medical record of an orthodontic patient”, form No. 030 / y “Control card for dispensary observation”, approved by the same order, registration form No. 030-1 / y-02 “Card ) help”, approved by the Order of the Ministry of Health of the Russian Federation No. 420 of December 31, 2002, “Form of an insert in the medical record of an outpatient (inpatient) patient when using assisted reproductive technologies”, approved by Order of the Ministry of Health of Russia No. 107n of August 30, 2012, etc.

The procedure for filling out an outpatient patient card

The title page is filled in at the registry office when the patient first contacts a medical organization. Subsequent records are kept exclusively by a doctor, medical workers with a secondary medical education, leading an independent appointment, fill out a register of patients receiving medical care on an outpatient basis. Cards of citizens entitled to receive a set of social services are marked with the letter “L” (next to the Card number). The Card reflects the nature of the course of the disease (injury, poisoning), as well as all diagnostic and therapeutic measures carried out by the attending physician, recorded in their sequence. The card is completed for each patient visit. Conducted by filling in the relevant sections. Entries are made in Russian, neatly, without abbreviations, all necessary corrections are made immediately, confirmed by the signature of the doctor filling out the Card. It is allowed to record the names of drugs in Latin.

When filling out the title page, identification documents are used, namely: for citizens of Russia - a passport of a citizen of the Russian Federation, for a sailor of a merchant ship - a sailor's identity card, for a serviceman of the Russian Federation - an identity card of a serviceman of the Russian Federation, for a foreign citizen - a passport or other document recognized as certifying identity in accordance with an international treaty of the Russian Federation, for a refugee - a certificate of consideration of an application or a refugee certificate, for stateless persons - a temporary residence permit, residence permit, documents recognized as identity cards of a stateless person in accordance with international treaties of the Russian Federation.

The place of work and position is indicated according to the patient.

Filling in the rest of the items is usually not difficult because there are text clues about their purpose.

Electronic medical record

An electronic medical record is intended to facilitate interaction between specialists and medical organizations, ensure continuity in examination and treatment, and provide an opportunity for the exchange of experience. A pilot project is currently underway to develop and test it. The status of an electronic medical record as a single document has not yet been fixed by law. In the workflow, paper information carriers are used.

The new electronic service is designed to ensure routine (including archival) storage and provision of authorized users, services and software applications with prompt access to standardized electronic medical documents and information as part of an integrated electronic medical record.

The integrated electronic medical record accumulates medical information received from medical organizations of all levels and provided by these organizations for storage in it.

The sources of data for the integrated electronic medical record are the medical information systems of the integrated electronic medical record of medical organizations that support the maintenance of the patient's electronic medical record, which contains personalized demographic data and information about the citizen's health, treatment plans, prescriptions and results of medical, diagnostic, preventive, rehabilitation, sanitary and hygienic and other measures.

In addition to medical documents, the integrated electronic medical record contains an integral history of the patient's life, including demographic and vital information, data on visits, hospitalizations, surgical interventions, vaccinations, socially significant diseases, disability and other regulated information.

In order to ensure the protection of personal data from unauthorized access and the integrity of the transmitted data, documents as part of an integrated electronic medical record contain an electronic signature of a medical worker and / or (depending on the regulations) of a medical organization that provided a medical document for use as part of an integrated electronic medical record.

The users of the System are:

• medical organizations, a doctor (including private practice doctors) and other medical workers who are obliged to observe medical confidentiality and use medical information from an integrated electronic medical record in the interests of diagnosing, treating or preventing a patient (the subject of an integrated electronic medical record);


• subjects of an integrated electronic medical record that have access only to their integrated electronic medical record;


• other persons and organizations who may be provided with depersonalized or aggregated information for the purposes of scientific or educational work, analysis or planning of healthcare activities.

Identification and authentication of users of the information system is carried out using the means of a qualified electronic signature operating within the framework of the Common Space of Trust.

Quality criteria for filling out an outpatient card

The legislator does not regulate the specific content of each medical record. They must be consistent, logical and thoughtful. In order to avoid "complaints" from the supervisory authorities, the patient's complaints are indicated most fully, using all the characteristics, the course of the disease is described in detail from the moment of their occurrence to the visit, the features of life that contribute to the disease, the general condition of the patient, and especially carefully - the state of the disease area. The diagnosis is established according to the International Classification of Diseases (ICD-10), its complications and concomitant diseases are indicated. Appointments (examinations, consultations), medications, physiotherapy are recorded, the issuance of a certificate of incapacity for work, certificates and preferential prescriptions is noted. Examination and treatment must comply with the standards for the provision of medical care for this disease, approved by the Ministry of Health of the Russian Federation in accordance with Art. 37 of the Federal Law of November 21, 2011 No. 323-FZ “On the Basics of Protecting the Health of Citizens in the Russian Federation”, clinical recommendations (treatment protocols) on the provision of medical care developed and approved by medical professional non-profit organizations (part 2 of article 76 of the Federal Law dated November 21, 2011 No. 323-FZ “On the fundamentals of protecting the health of citizens in the Russian Federation”), meet the quality criteria for filling out medical documentation approved by Order of the Ministry of Health of the Russian Federation dated July 7, 2015 No. 422an “On approval of criteria for assessing the quality of medical help."

Namely: all sections provided for by the outpatient card must be filled in as a separate document, there must be information on the availability of informed voluntary consents to medical interventions, as well as on refusals of them, information on the plan for examination and treatment of the patient, taking into account the clinical diagnosis, the patient's condition, the characteristics of the course of the disease, the presence of concomitant diseases, complications of the disease and the results of the diagnostics and treatment based on the standards of medical care, procedures for the provision of medical care, clinical recommendations (treatment protocols), information on prescribing and prescribing drugs in accordance with the established procedure ( Order of the Ministry of Health of Russia dated December 20, 2012 No. 1175n “On approval of the procedure for prescribing and prescribing medicines, as well as forms of prescription forms for medicines, the procedure for issuing these forms, their accounting and storage”), etc.

At repeated visits of the patient, the dynamics of the course of the disease is described in the same order, especially emphasizing its changes compared to the previous visit. In the outpatient card, milestone epicrises are compiled, consultations of the head of the department, conclusions of the medical commission are entered, for example, when prescribing drugs for medical use and using medical devices by decision of the medical commission of a medical organization (clause 4.7 "Procedure for the creation and operation of a medical commission of a medical organization" approved order of the Ministry of Health and Social Development of Russia dated May 5, 2012 No. 502n), information is provided on the examination of temporary disability, dispensary observation, information on hospitalizations and surgical interventions performed on an outpatient basis, on radiation doses received during X-ray examination, etc.

Item 35 serves to record the epicrisis. It should be noted that it is issued in case of departure from the service area of ​​the medical organization or in case of death (posthumous epicrisis).

In case of withdrawal, the second copy of the epicrisis is sent to the medical organization at the place of medical observation of the patient or is handed over to the patient.

In the event of the death of a patient, a postmortem epicrisis is drawn up, which reflects all the diseases, injuries, operations that have been transferred, and a posthumous final rubricified (divided into sections) diagnosis is made; the series, number and date of issue of the registration form "Medical death certificate" are indicated, as well as all causes of death recorded in it.

Access to information contained in the outpatient card

All information contained in the outpatient card is a medical secret. i.e., their disclosure is not allowed, including after the death of a person, on the basis of Parts 1, 2, Article 13 of the Federal Law of November 21, 2011 No. 323-FZ “On the Fundamentals of Protecting the Health of Citizens in the Russian Federation”. The very fact of contacting the clinic also refers to medical confidentiality. Part 4 of the above article indicates the categories of persons who are provided with information from medical records without the consent of the patient. It should be emphasized that employers, lawyers, notaries do not have the right to receive this information without the consent of the patient. Read more about this in another article of the FACULTY OF MEDICAL LAW "The Patient's Right to Medical Confidentiality".

The right of the patient to receive information contained in the outpatient card

Part 4 of Art. 22 of the Federal Law of November 21, 2011 No. 323-FZ “On the Fundamentals of Protecting the Health of Citizens in the Russian Federation”, it is established that the patient or his legal representative has the right to directly get acquainted with the medical documentation reflecting the state of his health, in the manner established by the authorized federal executive body authorities, and receive advice from other specialists on the basis of such documentation.

The patient or his legal representative has the right, on the basis of a written application, to receive medical documents reflecting the state of health, their copies and extracts from medical documents. The grounds, procedure and terms for the provision of medical documents (their copies) and extracts from them are established by the authorized federal executive body (part 5 of article 22 of the Federal Law No. 323 "On the fundamentals of protecting the health of citizens in the Russian Federation"). The prescribed procedure for providing the patient with medical documentation has not yet been approved. The legislator has not established the grounds for refusal or non-provision of medical documents to the patient. Thus, the medical organization is obliged to provide the patient or his legal representative with medical documents for review. In a written application, the patient is not required to explain the purpose for which he needs to obtain medical documents. The law does not provide for the collection of fees for the production of copies of medical documentation, an application for the issuance of documents must be registered in the register of incoming documentation, and copies of documents received by the applicant in the register of outgoing documentation. To date, the procedure for obtaining the original outpatient card is not provided.

In legislation, the legal representative of a patient who has been declared legally incompetent (due to a mental disorder) is his guardian; recognized as partially incapacitated - his trustee (Articles 29, 30 of the Civil Code of the Russian Federation). The legal representatives of minor patients are their parents, guardians, trustees. Other persons may obtain medical records based on the patient's power of attorney. Based on the principle of reasonableness, the period should be up to 10 days, by analogy with the period allotted by law for the satisfaction of individual consumer requirements. Violation of the patient's right in the form of unlawful refusal or failure to provide the patient with medical documents may entail not only administrative, but also criminal liability of officials. Article 5.39 of the Code of Administrative Offenses of the Russian Federation provides for liability for an unlawful refusal to provide a citizen in the prescribed manner with documents, materials affecting his rights and interests, or for the untimely provision of such documents, materials in the form of a fine. We can also talk about criminal liability by virtue of Article 140 of the Criminal Code of the Russian Federation for the unlawful refusal of an official to provide documents and materials collected in the prescribed manner that directly affect the rights and freedoms of a citizen, or for providing a citizen with incomplete or knowingly false information if these acts caused damage to the rights and legitimate interests of citizens

Liability cases

Since it is the primary medical documentation that certifies the facts and events that are important from a legal point of view, the current legislation provides for administrative and criminal liability in the following cases:

• violation of the rules for storage, acquisition, accounting or use of archival documents, with the exception of cases provided for in Article 13.25 of this Code (Article 13.20 of the Code of Administrative Offenses of the Russian Federation);


• official forgery: the introduction by an official into official documents of knowingly false information, as well as the introduction of corrections into these documents that distort their actual content, if these acts are committed out of mercenary or other personal interest (in the absence of signs of a crime under Part 1 of Article 292.1 of this Code) (Article 292 of the Criminal Code of the Russian Federation);


• theft, destruction, damage or concealment of official documents, stamps or seals, committed out of mercenary or other personal interest (part 1 of article 325 of the Criminal Code of the Russian Federation);


• falsification of evidence in a civil case by a person participating in the case, or his representative (Article 303 of the Criminal Code of the Russian Federation).

Also, improper filling out of an outpatient card can be qualified by the supervisory authority under Article 14.1 or 19.20 of the Code of Administrative Offenses of the Russian Federation as a violation of licensing requirements in the implementation of medical activities.