The SAMD 224 is a document that records the result of an instrumental examination - ultrasound, X-ray, computed or magnetic resonance imaging, functional diagnostics.
It describes which study was performed and on which equipment, which objects were examined, what was measured, what pathologies were identified and what conclusion the doctor came to.
Two scenarios of transthoracic echocardiography have been separately standardized. After signing, the document is sent to the RAMD.
How to create a document:
- Schedule the patient for a routine appointment.
To form a document, you must specify the following data in the patient's profile:
- Last name, first name.
- Paul.
- Date of birth.
- SNILS.
- The subject of the Russian Federation in which the patient lives or is registered.
Create a new protocol with the type «Протокол инструментального исследования»and fill in the date of birth of the patient.
«Вид протокола»Select the appropriate option in the field.
Important! The composition of the available and required blocks depends on the selected protocol type.
When choosing the type of protocol, the following «Трансторакальная эхокардиография (стандартный)»blocks become mandatory::
- Objects of research
- Vital signs
- Information about prosthetics
In «Объекты исследования»the and blocks«Сведения о протезах», you must specify information on the four heart valves.
Important! If the patient does not have an MHI or VMI policy, when filling out the protocol, you will need to select a contract for the provision of paid medical services.
Then, if necessary, fill in:
- Medical card.
- The form of medical care.
- Type of medical care.
- Conditions of medical care.
- Type of request.
- The place of medical care.
- The number of the research protocol.
The marked fields «Обязательно для ЕГИСЗ»must be filled in to transfer the document.
The referring doctor
If you have a referral, add information about the referring doctor.
You can specify the referring doctor in two ways:
- select from the directory;
- enter the data manually.
If the referring doctor works for your medical organization, select «Выбрать из справочника».
Specify the referring doctor and his position.
If the doctor works for another medical organization, select «Ввести вручную».
Fill in the information about the doctor.
To transfer to the EGISZ, you must specify the last name, first name, organization and position of the referring doctor.
If necessary, you can also specify:
- Middle name.
- SNILS.
- Address.
- A subject of the Russian Federation.
- Postal code.
- Telephone.
The block «Направивший врач»is optional.
Categories of diseases
If necessary, add one or more categories of diseases that are being investigated.
In each added entry, select«Категория заболевания (МКБ-10)»
Directional diagnosis
If necessary, select «Направительный диагноз (МКБ-10)».
Additionally, you can fill in the field«Описание направительного диагноза».
Instrumental research
Add information about the completed research.
It is necessary to specify at least one instrumental study.
Fill in the form:
- A type of instrumental research.
- The date and time of the start of the study.
- The date and time of the end of the study, if necessary.
If the study is related to radiation exposure, specify:
- Radiation load.
- The unit of radiation load measurement.
Important! The radiation load and its unit of measurement must be filled in together.
In the same block, if necessary, you can add information about equipment, consumables, and research modes.
Information about the equipment
Add the equipment and specify:
- Type of equipment.
- Name of the equipment.
Information about consumables
If consumables were used during the study, add them to the protocol.
Specify:
- The number of consumables.
- The name of the consumable.
Study modes
If necessary, add one or more study modes.
In each entry, select «Режим исследования».
Also, in the instrumental research block, you can specify the image quality and leave a comment on the image quality.
Objects of research
In the block, «Объекты исследования»specify the anatomical areas that were examined.
For each object, select:
- Anatomical localization.
- Laterality - if necessary.
- Serial number - if necessary.
If a pathology is detected during the examination of the object, turn on the switch«Выявлена патология».
Important! If at least one object has a switch «Выявлена патология»turned on, you need to fill in the block «Сведения о патологиях».
When choosing the type of protocol, the «Трансторакальная эхокардиография (стандартный)»block «Объекты исследования»is mandatory. Four objects need to be added:
- The aortic valve.
- Mitral valve.
- Tricuspid valve.
- The valve of the pulmonary artery.
Each valve must be specified once.
Vital signs
If necessary, add vital signs obtained during the study.
When choosing the type of protocol, «Трансторакальная эхокардиография (стандартный)»this block is mandatory.
Specify the date and time of the measurement.
If necessary, add a comment to the measurement.
Then add one or more metrics.
For each indicator, select «Витальный показатель»the way to specify the value.:
- Numeric with a unit of measurement.
- Text.
- Yes/no.
For a numeric value, specify:
- Meaning.
- The unit of measurement.
If necessary, you can also fill in the laterality and the sequence number.
You can add a reference interval to the indicator.
Specify a description of the reference interval.
If necessary, fill in additional information:
- The lower limit of the norm.
- The upper limit of the norm.
- The unit of measurement of the interval.
Important! If you specify the numerical boundaries of the reference interval, the lower boundary, the upper boundary, and the unit of measurement must be filled in together.
Information about pathologies
If a pathology is detected during the examination, add it in the block«Сведения о патологиях».
Pathology can be indicated in two ways:
- select from the directory;
- describe it in your own words.
When choosing an option, «Выбрать из справочника»fill in the field«Выявленная патология».
If there is no suitable value in the reference, select «Описать своими словами»and fill in the pathology description.
Additionally, you can specify:
- Comment.
- Laterality.
- Sequence number.
If necessary, add pathology characteristics.
For each entry, you must select:
- Characteristics of pathology.
- The value of the characteristic.
Important! If you have added a pathology characteristic, you must also specify its value.
Result of investigation
Fill in the results of the conducted research.
In the field, «Описание проведённого исследования»describe the research performed and the results obtained.
Then fill in the field«Заключение».
Both fields are required to submit the document to the USISZ.
If necessary, fill in the field«Рекомендации».
Information about prosthetics
When you select the type of protocol, an «Трансторакальная эхокардиография (стандартный)»additional required block appears«Сведения о протезах».
It is necessary to add information on four heart valves:
- Aortic.
- Mitral.
- Tricuspid.
- The valve of the pulmonary artery.
For each valve, select «Анатомическая локализация протеза».
If the prosthesis is not installed, leave the switch «Протез установлен»off.
If the prosthesis is installed, turn on the switch.
There are two ways to specify a device:
- select from the directory;
- describe it in your own words.
When selecting the directory, specify «Тип использованного устройства, имплантата».
When choosing a free description, fill in «Описание устройства».
Important! Even if the prosthesis is not installed on the valve, an entry for this valve must be added. All four valves should be indicated for standard transthoracic echocardiography.
Important! If «Протез установлен»the switch is on, you must specify the type of device or describe it in your own words.
Medical services provided
If necessary, add the medical services provided to the patient.
For each service, specify:
- The service rendered.
- The date and time of the service provision.
The block is optional, but inside the added record, the service and the date of its provision are required to be transferred to the EGISZ.
Clinical scales and questionnaires
If a clinical scale or questionnaire was used during the study, add them in the appropriate section.
Choose«Клиническая шкала или опросник».
If necessary, specify:
- The date and time of the scale calculation.
- The result of the calculation.
- The unit of measurement of the result.
- Interpretation of the result.
Important! The result of the scale calculation and the unit of measurement must be filled in together.
If the scale was evaluated by another healthcare professional, add it in the block«Медработник, проводивший оценку по шкале».
Specify:
- The medical professional who conducted the assessment.
- His position.
- Phone number - if necessary.
You can also add individual scale parameters.
For each parameter, select its value and specify the date and time.
Printed form
The printed form of the protocol can be generated at any stage of working with the document.
It may contain:
- Information about the medical organization.
- Patient data.
- Number and date of the protocol.
- Information about the conducted research.
- A directional diagnosis.
- Information about the equipment.
- Information about the research objects.
- Vital signs.
- Identified pathologies.
- The results of clinical scales.
- Medical services provided.
- Description of the study.
- Conclusion.
- Recommendations.
- Information about the medical workers who signed the document.
Sections that have not been filled in are not displayed in printed form.
Signing the document
When the protocol is completed, sign the document.
During the signing process, the system will check the required fields.
Pay attention to the filling:
- The type of protocol.
- Conditions of medical care.
- Places of medical care.
- A type of instrumental research.
- The date and time of the start of the study.
- Descriptions of the conducted research.
- Conclusions.
Also check the required patient information in his profile.
For standard transthoracic echocardiography, the required blocks must additionally be filled «Объекты исследования»in , «Витальные показатели»and «Сведения о протезах».
After successful signing, the document is transferred to the RAMD.
Frequently Asked Questions
Do I need to fill in all the protocol blocks?
No. Most of the additional blocks are filled in depending on the conducted research. The required fields for the Unified State Register of Legal Entities are marked directly in the form.
The exception is certain types of protocol. For example, when selecting «Трансторакальная эхокардиография (стандартный)»additional blocks «Объекты исследования», «Витальные показатели»and , become mandatory«Сведения о протезах».
Why can't I sign the protocol?
Check the marked fields«Обязательно для ЕГИСЗ», patient data, and required fields inside the added blocks.
For example, a document cannot be signed if the radiation load is specified without a unit of measurement, a pathology characteristic is added without a value, or the presence of pathology in the object is noted, but the block «Сведения о патологиях»is not filled in.
What should I do if the patient does not have an MHI or VMI policy?
Select a contract for the provision of paid medical services.
What should I do if the prosthesis is installed?
«Сведения о протезах»Turn on the switch in the block «Протез установлен»and select the device type from the reference list or describe the device in your own words.
Why are some filled-in fields missing from the printed form?
Not all information that is transmitted to the EGISZ is printed. For example, some of the information about the case of medical care is used in the formation of the SAMD, but is not displayed in the form.