Medical documentation is a system of documents of the established form intended for recording data necessary for the proper organization of medical care for the population, the activities of medical institutions and the study of the state of public health.
The main requirements for medical documentation: accuracy, medical literacy, clarity, completeness and timeliness of records. Medical documentation is divided into accounting and reporting.
Accounting documents that are filled in for one person are called individual record documents, such as an outpatient medical record, a medical history , a child’s development history, etc. The journal of registration of infectious diseases, an operational journal, etc. are called group accounting documents.
The main registration document in the outpatient clinic and clinic is the medical card of the outpatient patient, which includes all requests for medical aid, the results of the examination, the treatment prescribed and the final diagnosis. Accounting final (specified) diagnoses increases the reliability of the data, since the initial diagnoses are not always correct. In the hospital, the main accounting document is the medical history (see), and for drawing up the report - a map of the outgoing patient.
In children's consultations and clinics, the main accounting document is the history of the child's development.
In the sanitary epidemiological stations the main medical records are: a map of sanitary observation of the object (industrial enterprise, water source, canteen, etc.) and an epidemiological survey of the source of an infectious disease.
Reporting documents are a compilation of data contained in the records, and describe the state of public health and the activities of the medical institution (see Medical Reporting).