From Big Medical Encyclopedia

CASE HISTORY — the traditional name of group of the medical documents intended for record of overseeing by a condition of the patient during the entire period of treatment in treatment and prevention facility. In policlinics for adults And. the individual card of an ambulatory, in children's policlinics is — history of development of the child (see). In a hospital And. — the main primary document made on each receipt arriving irrespective of the purpose, the diagnosis of a disease and term of stay in a hospital.

And. reflects a contribution of many generations of domestic scientists to creation of logical scientific schemes of inspection of the patient, systems of creation of the diagnosis on the basis of assessment of difficult interaction of environmental factors, living conditions of an individual and biol, factors in development of diseases, in a comprehensive approach to treatment of the patient, but not a disease. It was paid much attention by M. Ya. Mudroye, G. A. Zakharyin, S. P. Botkin, A. A. Ostroumov, etc.

In 1968 the order M3 USSR No. 55 in hospitals And. it is replaced with the card of the inpatient. In clinics of scientific research institute and medical in-t maintaining special, more detailed documents, in many cases problemno oriented is authorized. Voyen. - the medical service kept the name «case history». New name I. reflects essence of the document more correctly.

In the card of the inpatient complaints of the patient, the anamnesis, data on the diseases postponed earlier, results of researches, the diagnosis, the conclusions of specialists and data on the performed operations, result of treatment in a hospital register, and in case of death its reason and circumstances is specified, during the carrying out pathoanatomical opening the conclusion of the pathologist is provided.

On the basis of the card of the inpatient recommendations about further treatment of the patient and dispensary observation behind it are formed; by definition of the mode of work, and in necessary cases — on establishment of disability. The card is used at repeated cases of hospitalization, during the studying of the long-term results of treatment and as the legal document. Therefore special requirements are imposed to an order of conducting entries in the map and to its storage. The card of the inpatient, as a rule, is subject to storage in medical archives of BC in the USSR within 25 years. Entries in the map shall provide a possibility of evaluation test and the present a wedge, inspections of the patient, on them it is possible to judge terms of statement a wedge, the diagnosis, diagnoses of a disease and treatment in the dostatsionarny period. The card shall not contain the data which are not important for diagnosis, assessment of a state and treatment of the patient.

Design of the card of the inpatient is carried out in the form established to M3 of the USSR on the special unified form consisting of the title page (cover) and loose leaves.

The map is kept in a certain sequence: at first fill in points of the title page containing the passport information about the patient, on the diagnosis of the directed establishment, about ways of delivery of the patient; the doctor of reception makes the diagnosis at receipt, makes necessary entries about results of inspection and poll in reception; the attending physician describes complaints of the patient, the anamnesis, specifies the estimated diagnosis and the plan of inspection, then consistently brings results of inspection of the patient, daily observations and ways of treatment, data of special researches. The card comes to the end epicrisis (see) and removal at the title page of the main data on the diagnosis, operational treatment, its complications, side effect of drugs, about the result of treatment.

The loose leaf (diary) is intended for record of dynamic observation and record by the doctor if there is a need, some conclusions and the description of actions. It is not recommended to provide on this leaf data on body temperature, pulse, the ABP, a respiration rate, a diuresis, to write down appointments. For these purposes there are loose leaves which are stored at the sister on duty. Results of laboratory, X-ray and other inspections paste in hronol. order. On the single loose leaf describe indications to operation, methods of anesthesia also fill in the protocol of operation. At an extract of the patient, including temperature and sheets of medical appointments, file all completed sheets in a cover of the card of the inpatient then it is signed by the attending physician and the manager. department; then the map is transferred to medical archive.

The structure of the card of the inpatient from single loose leaves allows to make in them records on typewriters in the dictation centers of BC. It releases time of doctors and increases culture of maintaining medical documents.

Comparison and rationally organized kliniko-statistical analysis of the data which are contained in big arrays of cards of inpatients allows to draw important scientific conclusions during the studying a wedge, pathologies, evolutions in development and the course of a disease, at assessment of various methods of treatment, their long-term results. The card is widely used at a statistical analysis of activity of BC, the list of the hospitalized patients etc.

For simplification of statistical processing of the data which are contained in the card of inpatients at an extract of the patient make the statistical card left a hospital.

The correct drawing up and maintaining the card of the inpatient has great educational value since accustoms the doctor to systematic observation, helps to develop a wedge, thinking.

See also Documentation medical .

G. F. Church.