Protocol of the operation (SAMD 189)

Related Articles:

• The protocol of examination by the attending physician (SAMD 191)
• Preoperative epicrisis (SAMD 217)
• Epicrisis in hospital discharge (SAMD 235)

How to create a document

1. Make an appointment for the patient.
2. 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.

1. Create a new protocol with the type «Протокол операции».

The fields in the document must be filled in:

• The role of the author of the document from the selected list

• Personnel involved in the surgical intervention:

• Patient's medical card type and enter the medical card number:

• The period of the operation: the date and time of the beginning and end of the operation. Select the blood group of the patient, specifying the blood type and Rhesus.

• Please indicate whether any operations were performed prior to surgery. If premedication and/or perioperative antibiotic prophylaxis has been performed, a description must be added (mandatory for EGISZ).

• Specify the diagnosis data before the operation:
  - Diagnosis according to ICD (mandatory for EGISZ).
  - The degree of validity of the diagnosis (mandatory for EGISZ).
  - Date and time of diagnosis.
  - The nature of the disease.
  - The type of injury by the method of injury.
  - Type of operation according to the directory of medical services.

• Add the equipment used during the operation:
  - Used equipment, according to the reference book.
  - Used devices, implants, according to the reference book.

• Fill in the description of the performed operation.

• Specify the pathologies and complications identified, and enter information about the amount of blood loss.

• Specify the diagnosis after surgery, the degree of validity of the diagnosis, and the nature of the disease.

When the document is ready, the doctor and the head of the clinic sign the document. The final document is downloaded in word format.

Frequently Asked Questions

Why is there no field when filling out the protocol?

There are required and optional fields in each SAMD. If the field is missing, it is optional to fill in and send to RAMD. If you need to use this field when filling out the protocol, please contact your personal manager.

Where can I find templates for filling out the protocol?

Operation templates are under development. If you have any suggestions about the displayed fields and/or information in the templates, please send them to your personal manager.