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- Preoperative epicrisis (SAMD 217)
- Protocol of the operation (SAMD 189)
- Epicrisis in hospital discharge (SAMD 235)
How to create a document
- Make an appointment for the patient.
- 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 «Осмотр лечащим врачом».
The fields in the document must be filled in:
- The role of the author of the document from the selected list
- Type of medical card
- Medical card number
The number of the outpatient clinic.You can also add cards from the patient's profile by moving the switcher «Взять номер медкарты из профиля пациента»to the right.
Fill in the details in the "Patient Information" section
If the patient's position is indicated in his profile, move the slider «Взять должность из профиля пациента»to the right, the data will be pulled up in the field«Должность»
In the sections «Жалобы», «Анамнез жизни», «Анамнез заболевания»you can select a previously created protocol for this patient or enter the data in the text field.
In the section«Физикальное обследование», specify the severity of the patient's condition and a description of the physical examination. Please note that these fields are required for transmission to the Unified State Register of Legal Entities.
Indicate the identified pathologies, if any, and complete the assessment.:
Specify vital parameters:
You can specify appointments, an examination plan, and a treatment plan by tweaking the existing protocol or specifying the data in the text field.
It is possible to add non-drug and drug treatment from the protocol if the data on prescribed medications and non-drug treatment were previously indicated in the patient's treatment plan.
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 aren't all filled-in fields printed?
The declared printed form according to order 530N may differ from the requirements specified in the SAMD.
Where can I find templates for filling out the protocol?
Hospital 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.