22.09.2017			12 – 20 – 403		Heads of medical organizations To the directors of the branches of the “TFOMS of the Volgograd Region” Heads of CMO
On the application of tariffs when providing medical care in outpatient setting

The state institution “Territorial Compulsory Medical Insurance Fund of the Volgograd Region” explains following a video conference meeting on the organization and payment of medical care in an outpatient setting.

Based on the Tariff Agreement in the field of compulsory health insurance of the Volgograd region for 2017, per unit of payment for medical care, including emergency care provided on an outpatient basis, the following are accepted:

Medical visits (for preventive purposes, for other purposes, when providing emergency medical care),

Visits to a paramedic (midwife) conducting an independent appointment (for preventive purposes, for other purposes, when providing emergency medical care),

Treatment (completed case, including during medical rehabilitation, during dispensary observation),

Completed medical examination case certain groups adult population,

Completed case of conducting preventive medical examinations of the adult population,

A completed case of medical examination of orphans and children in difficult life situations staying in inpatient institutions,

A completed case of medical examination of orphans and children left without parental care, including those adopted, taken under guardianship (trusteeship) in a foster or foster family,

Completed case of medical examinations of minors,

Visits to the health center,

Treatment and diagnostic services (computed tomography, magnetic resonance imaging, laboratory and diagnostic),

Per capita funding standard.

A visit is a patient’s contact with a doctor (except for doctors of paraclinical specialties), paramedical personnel conducting independent appointments, in an outpatient clinic organization (unit), as well as at home, including a set of necessary preventive, therapeutic and diagnostic services, with subsequent registration in medical record of an outpatient (diagnosis, prescription of examination, treatment, records of dynamic observation and other records based on observation of the patient).

TO visits for preventive and other purposesshould include:

Visits regarding examinations upon admission to study, to preschool institutions, when sending children to summer health camps, sanatoriums, boarding houses and other children's health organizations; inspections of contingents subject to periodic inspections; examinations of the population during medical examination, examinations when deciding whether to carry out preventive vaccinations;

Visits to pregnant women during normal pregnancy, visits to women who have applied for contraceptive use, etc.;

Patronage visits to healthy children in the first year of life;

Visits to health centers;

Visits in connection with obtaining certificates and other medical documents;

One-time visits regarding illness (injury, other condition);

Visits in connection with registration health resort card, registration of referrals for medical and social examination;

Consultations regarding illness (injury, other condition);

If, during a preventive examination, the doctor only suspected a disease, but did not make a diagnosis, and referred the patient to the appropriate specialist to establish a diagnosis, this visit to the doctor who conducted the examination should be taken into account as made for preventive purposes.

As part of each visit carried out at the expense of compulsory health insurance, medical organizations are required to keep records directions

An appeal regarding a disease is a completed case of treatment of a disease (injury or other condition) by a doctor of one specialty, a paramedic (midwife) with a frequency of at least two visits for one disease.

Appeal for the purpose of medical rehabilitation in an outpatient setting is a complete case of medical rehabilitation from doctors of several specialties and a set of treatment and diagnostic procedures in accordance with regulatory documents regulating the provision of medical rehabilitation.

A visit as a complete case consists of initial and repeat visits regarding the disease, treatment, diagnostic and rehabilitation activities, as a result of which recovery, improvement occurs, the patient is sent to a day hospital, hospitalized in a 24-hour hospital, for a medical and social examination, etc.

To appeals should also include the totality of visits regarding the pathology of pregnancy, visits regarding anomalies of refraction and accommodation (except for visits regarding presbyopia of persons aged 40 years and older), anomalies of speech, voice and hearing, etc.

To appeals should also include carrying outdispensary observationas part of the provision of primary health care to patients with chronic non-communicable diseases and patients at high risk of developing them, includingvisits within a month.

At the same time, cases of treatment (treatment with therapeutic purpose) one patient by different specialists (for example: a therapist and a physiotherapist; a paramedic and a traumatologist; a cardiologist and an ophthalmologist, etc.). When treating one pathology by doctors of different specialties, one of the specialists acts as the attending physician and bills the treatment for treatment purposes, while other specialists act as consultants and bills one-time visits for the disease.

As part of each application regarding a disease (injury, other condition), carried out at the expense of compulsory health insurance, medical organizations are required to keep records of directly performed visits as well as directions for laboratory testing in a centralized laboratory.

A visit for an urgent purpose in an outpatient setting - the provision of primary pre-hospital, primary medical, primary specialized health care (including in a clinic, hospital emergency department, at home when calling a medical professional) for sudden acute diseases and conditions (including injuries, poisoning), exacerbation chronic diseases, not dangerous to the patient's life.

As a pre-hospital health care emergency health care may turn out to be average medical workers(paramedics, midwives) who have the right to independently receive patients (determined by order of the chief physician for medical organization).

Medical assistance to patients who contact a medical organization with signs of an emergency condition is provided immediately. Emergency medical care at home is provided no later than 2 hours after the patient or other person receives a request for assistance. emergency care at home.

A mandatory condition for classifying a visit as an emergency visit in an outpatient clinic (unit) or at home is the provision of emergency diagnostic and treatment services using free of charge(at the expense of the medical organization providing medical care) medicines, medical devices and dressings necessary to provide emergency medical care in accordance with the list of vital and essential medicines and medical products necessary to provide primary health care in outpatient settings conditions in an emergency form within the framework of the Territorial Compulsory Medical Insurance Program.

When a patient comes to the emergency department of a hospitalfor emergency and urgent indications(by ambulance, self-referral, etc.) without subsequent hospitalization in this hospital in the case of therapeutic and diagnostic measures (including consultation and examination by a doctor for emergency indications for the purpose of differential diagnosis of a disease or condition), this visit is considered visiting in an emergencyand is presented for payment using a group of codes medical services 2.82.* “Doctor appointments in the hospital emergency department.” In the case of the use of drugs, medical devices and dressings, the primary medical documentation must contain a record of their use; when performing diagnostic procedures (for example: electrocardiography, radiography, examination of biomaterial, etc.) - the result of the study; when conducting emergency consultations indications – a complete detailed record of the examination and a specialist’s conclusion. In the case of examinations by doctors of different specialties for the purpose of differential diagnosis in the emergency room, each examination is billed as a separate visit for urgent purposes to a doctor of the corresponding specialty. In this case, each of the specialists makes a complete detailed record of the examination and a conclusion in the medical documentation. When a tomographic examination (computed tomography, magnetic resonance imaging) is carried out in a medical organization, when a patient visits the emergency department for emergency and emergency indications, a separate service is billed according to one of the codes:

2.82.26 “Doctor’s appointment in the emergency department of a hospital with a CT scan without contrast”

2.82.27 “Medical appointment in the emergency department of a hospital with a contrast-enhanced CT scan”

2.82.28 “Doctor’s appointment in the emergency department of a hospital with MRI without contrast”

2.82.29 “Medical appointment in the emergency department of a hospital with contrast-enhanced MRI”

according to the profile of the specialist who prescribed this study., with justification in the medical documentation for its implementation. The tariff for these codes includes the cost of a medical appointment and the relevant research. The remaining specialists (if necessary) submit their examinations invoiced using the usual codes for visits to the emergency department without conducting a corresponding study (code group 2.82.*, with the exception of the above).

Please note that cases of examination of patients in the emergency department by a specialist doctor for the purpose of selecting them for subsequent planned hospitalization are not invoiced for payment.

Medical organizations keep separate records of visits for preventive purposes (visits to a health center in connection with medical examination of certain population groups, clinical observation, preventive examination, consultations, etc.), emergency medical care and visits for diseases.

Visits made during the day by a patient to the same doctor (paramedical worker) are counted as one visit.

Tariffs for requests from a physiotherapist, physical therapy doctor, reflexology doctor include costs for physiotherapy, reflexology procedures, massage, etc.

Doctor consultations (consultative medical appointments)in medical specialties are used by medical organizations that have advisory (consultative and diagnostic) units and are counted as visits for preventive purposes. A mandatory condition for submitting a consultation case for payment at the rates of code group 2.81.* is the presence of a referral for consultation.

Execution casescomputed and magnetic resonance imaging performed on outpatients(including those insured outside the Volgograd region) are taken into account separately from outpatient visits and are billed for separate services.

Payment for outpatient medical care provided to insured persons at the place of attachment is carried out by insurance medical organizations for a completed visit, treatment or service, the cost of which includes an appointment with a specialist, medical manipulation and examinations prescribed by him. Payment for diagnostic studies (with the exception of computed and magnetic resonance imaging, services of centralized diagnostic laboratories (clinical diagnostic, cytological, prenatal screening, prenatal diagnostics)), carried out by referral from a medical organization to other medical organizations, is made in the form of mutual settlements between them without issuing invoices to medical insurance organizations.

Payment for primary health care provided by local therapists, local pediatricians, and general practitionersto the population not attached to this medical organization, is carried out by insurance medical organizations only when providing medical care in emergency conditions at rates for completed emergency visits. If necessary, repeat visits are made to non-precinct general practitioners and pediatricians and are paid at the rates for a one-time visit for a disease. Visits made to the population not attached to a given medical organization for the purpose of carrying out preventive vaccinations as part of national calendar preventive vaccinations and a calendar of preventive vaccinations for epidemic indications, for the purpose of dynamic monitoring of the state of development of the child, are paid by insurance medical organizations at the rates for a visit for preventive purposes to a general practitioner and non-local pediatrician. Medical examinations for the population not affiliated with this medical organization are not subject to payment.

Visit to the middle medical personnel

Visits by paramedical personnel (paramedics, midwives) are subject to accounting and are presented for payment in cases of self-administration in medical outpatient clinics, medical and paramedical health centers, first aid posts, including visits regarding procedures (with a recording of the examination in the medical documentation). Midwives of a medical outpatient clinic, a local hospital, a feldsher-midwife station, who independently receive (when assigned to them certain functions of the attending physician, assigned by order of the institution) pregnant women, postpartum women, gynecological patients, children of the first year of life can enter codes of the corresponding services in the account register for payment. Patients visiting the same health care provider during the day are counted as one visit.

Certain features of billing for cases of provision of primary specialized medical care in an outpatient setting

The formation of registers of information and invoices for medical care provided to an insured person during the process of allergen-specific immunotherapy (hereinafter referred to as ASIT) by an allergist-immunologist should be carried out in accordance with the following steps:

1. When you first contact an allergist-immunologist to make a diagnosis and conduct a preliminary examination to identify indications for ASIT (examination by a doctor, laboratory examination and diagnostic procedures – skin tests, prescription of a treatment regimen) when creating registers of information and invoices, the medical service code is used:2.78.7 – Contact an allergist-immunologist for therapeutic purposes.It is permissible to bill at the initial stages of “titration” the dose of allergodrug treatment for therapeutic purposes for several visits to administer the drug of one concentration, until reaching a constant concentration of the drug for long-term ASIT.

2. When directly conducting ASIT according to the scheme prescribed by the allergist-immunologist, when creating registers of information and bills, the medical service code is used:2.88.9 – One-time visit to an allergist-immunologist regarding a disease.

If, during the procedure for introducing the allergen(s) according to the prescribed scheme, complications or exacerbations arose and medical care was required directly from a doctor using medications, then when creating registers of information and invoices, the medical service code is used:2.80.15 – Emergency visit to an allergist-immunologist.

The formation of registers of information and invoices for medical care provided to an insured person in the process of using laser technologies in the treatment of diseases of the organ of vision should be carried out according to service code 2.78.46 “Contacting an ophthalmologist with the use of laser technologies for therapeutic purposes.” A special feature of visiting an ophthalmologist using laser technologies for therapeutic purposes is the presence of two visits, at least one of which must be about laser photocoagulation of the retina, which is necessarily reflected in the medical documentation. This service includes all necessary diagnostic examinations on the day of laser coagulation. The number of courses (stages), frequency of use and volume of intervention are determined individually by an ophthalmologist with mandatory indication in the primary medical documentation.

“TFOMS of the Volgograd Region” asks you to carefully read the procedure for generating accounts and strictly comply with the requirements of the Tariff Agreement. Heads of medical organizations need to take personal control over the implementation of volumetric indicators for outpatient medical care, bring this information to the attention of doctors and nursing staff who independently receive patients.

The article specifies the provisions of the program of state guarantees of free medical care to citizens based on standards of medical care, clinical recommendations, and lists of medications. The state guarantees free provision of citizens with medications from the List of Vital and Essential Medicines when providing medical care in inpatient settings. However, a number of by-laws establish the requirement to comply with standards of care and clinical recommendations. The regulations of the Federal Compulsory Medical Insurance Fund regulate the examination of the quality of medical care, including compliance with standards of medical care and clinical recommendations. Federal regulations also regulate the conduct of state and departmental quality and safety control medical activities. According to these regulatory legal acts, compliance by medical organizations with standards of medical care is a mandatory requirement. But subject to the provisions of all federal regulations, the doctor has the right to prescribe any medications based on the objectives of the treatment process and the patient’s health status.

Keywords: standards of medical care, clinical guidelines, medications.

For quotation: Alexandrova O.Yu. The right of citizens to drug provision when providing medical care in a hospital setting // RMZh. 2017. No. 18. pp. 1307-1311

The right of citizens for the medicines in the provision of medical care in stationary conditions
Alexandrova O. Yu.

Moscow Regional Research and Clinical Institute named after M.F. Vladimirskiy

The article considers the statements of the program of the state guarantees for the provision of free medical care to the citizens on the basis of medical assistance standards, clinical recommendations, lists of medicines. The state guarantees free drug provision of the citizens in medical settings with medicines from the Vital and Essential Drugs List. However, a number of by-laws regulate the requirement to comply with the standards of medical care and clinical recommendations. Normative acts of the Federal Compulsory Medical Insurance Fund regulate the examination of the medical care quality, including compliance with standards of medical care and clinical recommendations. Federal laws also regulate the carrying out expert examination of state and departmental medical quality and safety control. According to these legal acts, compliance by medical organizations with the standards of medical care is a mandatory requirement. But if the provisions of all federal regulatory legal acts are observed, the physician has the right to prescribe to the patient any medications based on the tasks of the medical process and the patient's state of health.

Key words: standards of medical care, clinical recommendations, medicines.
For citation: Alexandrova O. Yu. The right of citizens for the medicines in the provision of medical care in stationary conditions // RMJ. 2017. No. 18. P. 1307–1311.

The article is devoted to the right of citizens to drug provision when providing medical care in a hospital setting

Relevance

A doctor in the pulmonology department of a hospital has the opportunity to treat a patient with medications available in the department. These drugs are included in the List of Vital and Essential Medicines (VED), but are not included in the standard of medical care (SMC) for a patient with this disease. Clinical guidelines recommend other drugs. Does a doctor have the right to prescribe medications included in the EMS or clinical recommendations? To answer this question, let's consider the requirements of regulatory legal acts governing the provision of medical care.
In Part 2 of Art. 80 Federal Law dated November 21, 2011 No. 323-FZ “On the fundamentals of protecting the health of citizens in Russian Federation"(hereinafter referred to as the Federal Law “On the Fundamentals of Health Protection”) says:
“When providing, within the framework of the state guarantee program, free medical care to citizens, primary health care in a day hospital and in an emergency, specialized medical care, including high-tech, emergency medical care, including emergency specialized, palliative medical care in In stationary conditions, citizens are provided with medicines for medical use included in the list of vital and essential medicines...”
That is, medications from the list of Vital and Essential Drugs are provided free of charge for the treatment of citizens when providing medical care:
in hospitals;
in day hospitals;
when providing emergency medical care;
when providing primary health care (only in a day hospital and in an emergency).
When providing primary health care in an outpatient setting, medications are not guaranteed to citizens, i.e. they are not provided free of charge.
The exception is separate categories citizens who are provided with measures social support, including the provision of drugs for treatment on an outpatient basis, from the federal budget (so-called “federal beneficiaries”) or from regional budgets (“regional beneficiaries”), but not from compulsory health insurance (CHI).
The compulsory medical insurance system never finances the use of drugs to treat patients on an outpatient basis, i.e. It is impossible to use compulsory medical insurance funds to provide patients with medications during treatment on an outpatient basis.
When providing medical care in inpatient conditions and in a day hospital, medications will be used that are available in the medical organization and which were purchased by the medical organization with compulsory medical insurance funds intended to pay for medical care in a hospital at the full rate, including medications. First of all, we mean drugs included in the list of vital and essential drugs.
The list of vital and essential drugs in the latest edition was approved by the order of the Government of the Russian Federation dated December 28, 2016 No. 2885-r “On approval of the list of vital and essential drugs for medical use for 2017” and contains international generic names LP. Medicines from the List of Vital and Essential Drugs are guaranteed to citizens in accordance with Part 2 of Art. 80 of the Federal Law “On the Fundamentals of Health Protection”. Thus, the state guarantee of free drug provision of medical care is the List of Vital and Essential Drugs.
A medical organization is obliged, if indicated, to prescribe and provide medications to a patient on inpatient treatment, and the compulsory medical insurance system is obliged to pay for the medical care provided by the medical organization.
There is another type of document containing lists of medicines - this is the SMP.
Part 1 art. 37 of the Federal Law “On the Fundamentals of Health Protection” determines: “Medical care is organized and provided in accordance with the procedures for providing medical care, mandatory for all medical organizations on the territory of the Russian Federation, as well as on the basis of standards of medical care.” From this formulation it follows that only procedures for the provision of medical care are mandatory, and emergency medical services are not strictly mandatory.
In accordance with paragraph 2 of Art. 79 “Responsibilities of Medical Organizations” of the Federal Law “On the Fundamentals of Health Protection”, a medical organization is obliged to: “organize and carry out medical activities in accordance with legislative and other regulatory legal acts of the Russian Federation, including procedures for the provision of medical care, and based on standards of medical care...” That is, the norm of Art. 37: “...based on standards of care.”
Thus, from the point of view of legislation, SMPs are not strictly mandatory today. At the same time, SMP are approved by orders of the Russian Ministry of Health, i.e. they are officially subordinate regulatory legal acts (NLA) at the federal level. Judicial practice shows that violation of the norms of the federal normative legal acts (order of the Ministry of Health of Russia when carrying out medical activities) is interpreted by the courts as illegal behavior, and, therefore, violations of these normative legal acts can lead to legal liability of medical organizations.
In regulations governing the organization and financing of medical care, the concept of standard of medical care is repeatedly used. All current legal regulations refer exclusively to SMP developed and approved at the federal level. No regional standards (medical-economic, etc.) are mentioned in the federal-level legal regulations.
Despite the absence of strict mandatory compliance with the SMP in the law, subordinate Federal legal regulations form the ideology of their mandatory implementation.
In Part 3. Regulations on state control quality and safety of medical activities (approved by Decree of the Government of the Russian Federation of November 12, 2012 No. 1152) it is said:
“State control is exercised by:
c) conducting inspections applications organizations carrying out medical activities and individual entrepreneurs procedures for providing medical care and standards of medical care...”
In the Administrative Regulations of the Federal Service for Surveillance in Healthcare approved by Order of the Ministry of Health of Russia dated January 23, 2015 No. 12n for the execution of the state function of implementing state control over the quality and safety of medical activities by conducting inspections of the application of procedures for the provision of medical care by medical organizations and individual entrepreneurs and standards of medical care, the subject of state control (supervision) is “the application of procedures for the provision of medical care by organizations and individual entrepreneurs carrying out medical activities and standards of medical care(hereinafter referred to as mandatory requirements).”
The normative legal acts regulating the activities of subjects and participants of compulsory health insurance also use the concept of standard of care. Order of the Federal Compulsory Medical Insurance Fund (FFOMS) “On approval of the Procedure for organizing and monitoring the volumes, timing, quality and conditions of providing medical care under compulsory health insurance” dated December 1, 2010 No. 230 (as amended by Order of the FFOMS dated 21 July 2015 No. 130) failure, untimely or improper performance of necessary or performance of diagnostic and (or) unindicated, unjustified from a clinical point of view for the patient therapeutic measures, surgical interventions in accordance with standards of medical care is a defect in medical care.
Thus, despite the absence in the law of a requirement for strict mandatory implementation of emergency medical services, subordinate regulations at the federal level form the ideology of their mandatory implementation, including when conducting inspections of medical organizations by various inspection authorities. Medical organizations in such conditions are focused on compliance with EMS.
Hence, Medical organizations try their best to provide patients with medications included in the emergency medical care. At the same time, the drugs included in the List of Vital and Essential Medicines do not coincide with the drugs included in the SMP.
The law uses another concept - “for health reasons.” In Part 5 of Art. 37 of the Federal Law “On the Fundamentals of Health Protection” states: “Prescription and use of medicines, medical devices and specialized products therapeutic nutrition, not included in the relevant standard of medical care, is allowed in case of medical indications (individual intolerance, for health reasons) by decision of the medical commission.”
In Part 3. Art. 80 of the Federal Law “On the Fundamentals of Health Protection” says:
“When providing medical care within the framework of the program of state guarantees of free provision of medical care to citizens and territorial programs of state guarantees of free provision of medical care to citizens, the following are not subject to payment from the personal funds of citizens:
2) purpose and use according to medical indications medicines, not included to the list of vital and essential medications, ‒ in cases of their replacement due to individual intolerance, according to vital indications...”
The concept “for health reasons” is also used in the by-laws.
In clause 4.7 of the order of the Ministry of Health and Social Development of Russia dated May 5, 2012 No. 502 “On approval of the procedure for the creation and activities of a medical commission of a medical organization” (clause 4.7 was introduced by order of the Ministry of Health of Russia dated December 2, 2013 No. 886n) it is stated that the medical commission carries out :
“making decisions on prescribing medications in the presence of medical indications (individual intolerance, according to vital indications):
not included in the appropriate standard of care;
by trade name."
In the order of the Ministry of Health of Russia dated December 20, 2012 No. 1175 “On approval of the procedure for prescribing and prescribing medications, as well as forms of prescription forms, the procedure for completing these forms, recording and storing them” in paragraph 3 of Appendix 1 “Procedure for prescribing and prescribing medications drugs" says:
“The prescription and prescription of medications is carried out in accordance with the standards of medical care.
The prescription of medications that are not included in the relevant standard of medical care is permitted in case of medical indications (individual intolerance, according to vital indications) by decision of the medical commission...”
But, despite the fact that the concept “for health reasons” is used in the law and in the by-laws, there is no definition of this concept either in the law or in the by-laws.
In Art. 32 “Medical care” of the Federal Law “On the Fundamentals of Health Protection” provides a classification of medical care according to the form of provision:
“The forms of medical care are:
1) emergency - medical care provided for sudden acute diseases, conditions, exacerbation of chronic diseases that pose a threat to the patient’s life;
2) emergency - medical care provided for sudden acute diseases, conditions, exacerbation of chronic diseases without obvious signs threats to the patient's life;
3) planned ‒ medical care that is provided during preventive measures, for diseases and conditions that are not accompanied by a threat to the patient’s life, that do not require emergency and emergency medical care, and delaying the provision of which for a certain time will not entail a deterioration in the patient’s condition, a threat to his life and health."
Planned medical care differs from emergency and urgent care, based on the above definitions, in that its provision can be delayed indefinitely without harm to the life and health of the patient. Emergency and urgent medical care refers to the so-called urgent medical interventions. IN Methodical recommendations“Emergency medical care in the compulsory medical insurance system. Stage of formation, development prospects" (letter of the Ministry of Health of Russia No. 14-0/10/2-2564 and FFOMS No. 7155/30 dated September 26, 2012) states: “A medical intervention is urgent, requiring compliance with certain requirements for the timing of its commencement , calculated from the moment a patient in need of urgent or emergency medical care contacts a medical organization.”
In paragraph 2 of Art. 11 “Inadmissibility of refusal to provide medical care” of the Federal Law “On the Fundamentals of Health Protection” states: “Emergency medical care is provided by a medical organization and a medical worker to a citizen immediately and free of charge. Refusal to provide it is not allowed...”
The responsibilities of medical organizations (including medical organizations of the private healthcare system) in accordance with paragraph 1 of Art. 79 of the Federal Law “On the Fundamentals of Health Protection” includes the obligation to “provide citizens with emergency medical care.”
The main criterion for emergency medical care, as follows from the definition given in Art. 32 of the Federal Law “On the Fundamentals of Health Protection” is the presence of life-threatening conditions. Life-threatening conditions are listed in the order of the Ministry of Health and Social Development of Russia dated April 24, 2008 No. 194n “On approval of Medical criteria for determining the severity of harm caused to human health.”
The qualifying sign of a life-threatening condition is that life threatening conditions cannot be compensated by the body on its own and usually end in death. It is in these conditions that medical organizations, in accordance with Art. 11 and 79 of the Federal Law “On the Fundamentals of Health Protection” are required to provide medical care (regardless of whether those in need of such assistance are citizens of the Russian Federation or not, insured in the compulsory medical insurance system or not).
The responsibilities of medical organizations do not apply to the provision of emergency medical care (“without obvious signs of a threat to the patient’s life”). However, a medical organization de facto cannot fail to provide emergency medical care not only in case of obvious signs of a threat to life, but also in conditions without obvious signs of a threat to life, when failure to provide medical care can lead to a life-threatening condition.
Let us recall that failure to provide assistance to a patient without good reason by a person obligated to provide it in accordance with the law or with a special rule, if this resulted in the death of the patient through negligence or the infliction of grave or moderate harm to his health, is a crime (Article 124 of the Criminal Code of the Russian Federation). And it doesn’t matter how this medical care was qualified - as emergency or emergency. The result that is important is the death of the patient or serious or moderate harm caused guilty.
In connection with the above, in the absence of a definition of the concept “for vital reasons” in the legal acts, one can focus on the definitions enshrined in the law. In our opinion, the concept of medical care for life-saving reasons should not be limited to the concept of emergency medical care (i.e., the presence of obvious signs of a threat to life, listed in Order of the Ministry of Health and Social Development of Russia 194n). According to vital indications, medical assistance is also provided when at the time of its provision there are no obvious signs of a threat to life, but when failure to provide medical care can lead to a life-threatening condition. That is, delaying medical intervention impossible for an indefinite period due to the fact that this condition (disease) cannot be compensated by the body on its own and usually ends in death.
Naturally, there are a very large number of such diseases and conditions. It is most likely impossible to name them all. Moreover, the same disease can be compensated by the body for quite a long time, and then begin to progress rapidly and end in death. Or the progression of the disease may not be associated with the disease itself, but with the weakening of the body by concomitant diseases.
Thus, the concept of “for vital reasons” is used in everyday medical practice, especially in medical organizations that provide medical care to patients with severe progressive diseases.
The question arises, who determines the patient’s health status, when medical care should be provided according to life-saving indications and, accordingly, the patient should be provided with medications when providing medical care? The answer from legal acts regulating medical activities is clear: the medical commission of a medical organization.
It is the medical commission of the medical organization that prescribes medications for vital indications that are not included in the SMP (Part 5 of Article 37 of the Federal Law “On the Fundamentals of Health Protection”; Clause 3 of Order of the Ministry of Health of Russia dated December 20, 2012 No. 1175n “On approval of the order of prescription and prescribing medications, as well as forms of prescription forms for medications, the procedure for completing these forms, their recording and storage").
It is by decision of the medical commission that patients, when providing medical care in a hospital setting, are prescribed drugs that are not included in the List of Vital and Essential Medicines, in case of their replacement for health reasons (clause 27 of the order of the Ministry of Health of Russia dated December 20, 2012 No. 1175n “On approval of the procedure for prescribing and prescribing medications, as well as forms of prescription forms for medications, the procedure for completing these forms, their recording and storage”). The medical organization in which the medical commission works is legally responsible for the prescription (non-prescription) of drugs for life-saving indications.
Thus, a mechanism is created to guarantee the provision to the patient of medications necessary for health reasons. In addition, it is necessary to understand the role of the attending physician in the onset of civil liability of a medical organization. In accordance with Art. 1068 Civil Code of the Russian Federation entity is found guilty if the guilt of his employee is proven.
In accordance with Part 2 of Art. 73 “Responsibilities of medical workers and pharmaceutical workers” of the Federal Law “On the Fundamentals of Health Protection” medical workers are obliged“provide medical care in accordance with their qualifications, job descriptions, service and job responsibilities..." There is no indication in the text of the law that medical workers are obliged to perform emergency medical care or prescribe medications exclusively from the List of Vital and Essential Medicines. The doctor must treat the patient in the most in effective ways and means. The consequences of a doctor’s actions lie not only on him, but also on the medical organization in which he works.
There is another type of document that is named in the law and contains instructions on the drug. We are talking about developed by the professional medical community clinical recommendations (treatment protocols) various diseases.
In Part 2 of Art. 76 "Professional non-profit organizations created by medical workers and pharmaceutical workers" of the Federal Law "On the Fundamentals of Health Protection" says:
“Professional non-profit organizations may, in accordance with the procedure established by the legislation of the Russian Federation, take part in the development of norms and rules in the field of health protection, in resolving issues related to violation of these norms and rules, procedures for the provision of medical care and standards of medical care, training and advanced training programs for medical workers and pharmaceutical workers, take part in the certification of medical workers and pharmaceutical workers to obtain qualification categories»;
“Medical professional non-profit organizations develop and approve clinical recommendations (treatment protocols) regarding the provision of medical care...".
Clinical recommendations (treatment protocols) (hereinafter referred to as CR), unlike EMS, must contain an algorithmic component of medical care for certain diseases. The CR should contain a description of the diagnostic and treatment process in a specific clinical situation, depending on its development. It is possible to include in the KR additional therapeutic and diagnostic measures and medications in relation to EMS in certain clinical situations.
It is necessary to understand that CDs can be the basis for expert assessment the correctness of medical care from the point of view of the most effective, maximum possible modern stage, and at the same time, diagnostic and treatment methods already accepted by the professional medical community. However, the Kyrgyz Republic is not a state guarantee of free medical care.
At the same time, in 2015, a number of legal acts were adopted, essentially obliging to treat the Kyrgyz Republic as documents regulating the activities of medical organizations.
By FFOMS Order No. 130 of July 21, 2015, amendments were made to FFOMS Order No. 230 of December 1, 2010 “On approval of the Procedure for organizing and monitoring the volume, timing, quality and conditions of providing medical care under compulsory health insurance”:
"h. 13. paragraph 67 shall be supplemented with new paragraphs with the following content:
“Defects in medical care and/or violations in the provision of medical care:
failure to perform, untimely or improper performance of necessary or performance of unindicated, unjustified from a clinical point of view for the patient diagnostic and (or) therapeutic measures, surgical interventions in accordance with the procedures for the provision of medical care, standards of medical care and (or) clinical recommendations (treatment protocols).”
Thus, failure to comply with the requirements of the Kyrgyz Republic becomes a defect in medical care in the compulsory medical insurance system.
Order of the Ministry of Health of Russia dated May 10, 2017 No. 203n “On approval of criteria for assessing the quality of medical care” included among the criteria for assessing the quality of medical care both in outpatient settings and in day hospitals and hospitals:
establishment clinical diagnosis based on medical history, examination, laboratory, instrumental and other research methods, results of consultations with medical specialists provided for by the standards of medical care, as well as clinical recommendations (treatment protocols) on the provision of medical care;
carrying out correction of the examination plan and treatment plan taking into account the clinical diagnosis, the patient’s condition, the characteristics of the course of the disease, the presence concomitant diseases, complications of the disease and the results of treatment based on standards of care and clinical guidelines.
The above conclusions are summarized in Table 1.

Literature

1. Federal Law of November 21, 2011 No. 323-FZ “On the fundamentals of protecting the health of citizens in the Russian Federation”.
2. Order of the Government of the Russian Federation of December 28, 2016 No. 2885-r “On approval of the list of vital and essential drugs for medical use for 2017”.
3. Decree of the Government of the Russian Federation of November 12, 2012 No. 1152 “On approval of the Regulations on state control of the quality and safety of medical activities.”
4. Order of the Ministry of Health of Russia dated December 20, 2012 No. 1175n “On approval of the procedure for prescribing and prescribing medications, as well as forms of prescription forms for medications, the procedure for processing these forms, their recording and storage.”
5. Order of the Ministry of Health of Russia dated May 10, 2017 No. 203n “On approval of criteria for assessing the quality of medical care.”

The Program provides free of charge:
primary health care, including primary pre-medical, primary medical and primary
specialized;
specialized, including high-tech, medical care;
ambulance, including specialized emergency medical care;
palliative care in medical organizations.

Primary health care is the basis of the medical care system and includes measures for the prevention, diagnosis, treatment of diseases and conditions, medical rehabilitation, monitoring the course of pregnancy, formation healthy image life and sanitary and hygienic education of the population.

Primary health care is provided free of charge on an outpatient basis and in a day hospital, in a planned and emergency form.

Primary pre-hospital health care is provided by paramedics, midwives and other medical workers with secondary medical education.

Primary medical care is provided by general practitioners, local physicians, pediatricians, local pediatricians and general practitioners (family doctors).

Primary specialized health care is provided by medical specialists, including medical specialists from medical organizations providing specialized, including high-tech, medical care.

Specialized medical care is provided free of charge in inpatient and day hospital settings by medical specialists and includes prevention, diagnosis and treatment of diseases and conditions (including during pregnancy, childbirth and postpartum period), requiring the use of special methods and complex medical technologies, as well as medical rehabilitation.

High-tech medical care, which is part of specialized medical care, includes the use of new complex and (or) unique methods treatment, as well as resource-intensive treatment methods with scientifically proven effectiveness, including cellular technologies, robotic technology, information technology and genetic engineering methods developed on the basis of advances medical science and related branches of science and technology.

Ambulance, including specialized emergency medical care, is provided to citizens in an emergency or emergency form outside a medical organization, as well as on an outpatient and inpatient basis in case of illnesses, accidents, injuries, poisoning and other conditions requiring urgent medical intervention.

Ambulance, including specialized emergency medical care, is provided to citizens by medical organizations of the state healthcare system free of charge.

When providing emergency medical care, if necessary, medical evacuation is carried out, which is the transportation of citizens in order to save lives and preserve health (including persons being treated in medical organizations that do not have the ability to provide the necessary medical care for life-threatening conditions, women during pregnancy, childbirth, the postpartum period and newborns, persons affected by emergencies and natural disasters).

Palliative care is provided free of charge in outpatient and inpatient settings by medical professionals trained to provide such care, and is a set of medical interventions aimed at relieving pain and alleviating other severe manifestations of the disease in order to improve the quality of life of terminally ill citizens.

Medical assistance is provided in the following forms:
emergency - medical care provided for sudden acute diseases, conditions, exacerbation of chronic diseases that pose a threat to the patient’s life;
emergency - medical care provided for sudden acute diseases, conditions, exacerbation of chronic diseases without obvious signs of a threat to the patient’s life;
planned - medical care that is provided during preventive measures, for diseases and conditions that are not accompanied by a threat to the patient’s life, that do not require emergency and emergency medical care, the delay of which for a certain time will not entail a deterioration in the patient’s condition, a threat to his life and health .

Medical assistance to orphans and children without parental care is provided in the form of:
primary health care;
emergency, including specialized emergency medical care;
specialized, including high-tech, medical care;
palliative care.

The medical service of in vitro fertilization (hereinafter - IVF) at the expense of compulsory medical insurance is provided on an outpatient basis and in a day hospital in accordance with Orders of the Ministry of Health of the Russian Federation dated October 30, 2012 N 556n "On approval of the standard of medical care for infertility using assisted reproductive technologies" , dated 08/30/2012 N 107n “On the procedure for using assisted reproductive technologies, contraindications and restrictions on their use,” patients with a compulsory medical insurance policy are sent to a committee for selecting patients for the IVF procedure.

Conditions and procedure for providing free medical care by medical organizations

Medical care is provided by medical organizations with a license to carry out medical activities. In accordance with compulsory medical insurance agreements, medical assistance to insured citizens
provided upon presentation compulsory medical insurance policy and an identity document. Emergency medical care is provided regardless of the availability of a compulsory medical insurance policy and an identity document.

Emergency medical care is provided to a citizen immediately by the medical organization to which he applied. If the specified medical organization cannot provide the necessary medical care, the medical organization ensures the transfer of the citizen to another medical organization that provides for the provision of the necessary medical care.

Emergency and emergency medical care is provided to foreign citizens who are not entitled to compulsory medical insurance free of charge until the threat to the patient’s life or the health of others has passed.

Medical care for conditions that do not require round-the-clock medical observation and treatment for medical reasons is provided to citizens on an outpatient basis, including in day hospital beds in conditions that provide for medical supervision during the day, but do not require round-the-clock medical observation and treatment.

For conditions that require round-the-clock medical observation and treatment for medical reasons, medical care is provided in a round-the-clock hospital setting.

Consultations and treatment at research institutes and clinics of the Russian Federation for medical reasons are carried out in accordance with current regulatory legal acts in the direction of the Ministry of Health of the Astrakhan Region.

The administration of the medical organization participating in the implementation of the Program ensures the posting of information for citizens on the implementation of their legitimate interests and rights to receive free medical care of the appropriate volume and quality within the framework of the Program, including normative or other regulatory documents (their individual provisions). In all main departments of a medical organization (in the reception area and lobbies of outpatient clinics, in waiting rooms and other departments of hospitals), accessible visual information for patients is posted in a visible place and on the official website on the Internet information and communication network, which contains:

1) full name of the medical organization indicating:
legal address;
contacts (phones, email);
structures of a medical organization;
driving directions (map);
transport accessibility;
work schedule of a medical organization;
schedule for receiving citizens by the head and other authorized persons of the medical organization;
work schedule and visiting hours of medical workers;
information about the education and qualifications of medical workers;
insurance medical organizations with which the medical organization works (full name, address, contact phone number, address Email);
2) information about the medical activities carried out (copies of licenses for all types of activities);
3) a list of regulatory organizations to which the patient can contact in the event of conflict situations, indicating addresses, contact numbers and email;
4) information about the possibility of receiving medical care under the Program, including a copy of the Program;
5) rules for registering for an initial appointment/consultation/examination;
6) information on the timing and procedure for conducting clinical examination of the population in a medical organization;
7) hospitalization rules (waiting periods for planned hospitalization and required documents);
8) information about the rights and responsibilities of citizens in the field of health care;
9) information about the list of paid medical services indicating prices in rubles, information about the conditions, procedure, form of provision of medical services and the procedure for their payment;
10) information about vacancies in a medical organization;
11) feedback mechanisms, including the possibility of posting a request on the website of a medical organization (form for submitting an electronic request) and the “question-answer” section.

In addition, a mailbox with the inscription “For letters to the manager”, as well as a book of complaints and suggestions, should be located in a place accessible to visitors.

The operating procedure of a medical organization is determined by the founder.

Under the Program, the patient (his legal representative, authorized representative) has the right, on the basis of a written application, to receive medical documents, their copies and extracts from medical documents reflecting the state of health, in accordance with the legislation of the Russian Federation.

Within the framework of the Program, when providing medical care, a necessary precondition for medical intervention is the giving of informed voluntary consent of a citizen or his legal representative to medical intervention on the basis of complete information provided by a medical worker in an accessible form about the goals, methods of providing medical care, and the risks associated with them, possible options medical intervention, its consequences, as well as the expected results of medical care in accordance with the legislation of the Russian Federation.

Within the framework of the TP, compulsory medical insurance is not carried out:
conducting mandatory preliminary and periodic medical examinations of the adult population;
medical support for sporting events, health work camps, sports camps, children's health camps, mass cultural and social events;
medical examination of citizens for intoxication (alcohol, drugs or other toxic);
psychiatric examination;
examination for medical contraindications to management vehicle;
examination for the presence of medical contraindications to gun ownership;
other types of medical examination, established by law Russian Federation;
anonymous diagnosis and treatment (except for the prevention, detection and treatment of persons infected with human immunodeficiency viruses);
cosmetology assistance.

When providing medical care under the Program, transportation and storage in the morgue of biological material received for research, corpses of patients who died in medical and other organizations, and disposal of biological material are not subject to payment at the expense of citizens’ personal funds.

Conditions and procedure for the provision of primary and primary specialized health care in outpatient clinics (units)

When providing primary and primary specialized health care in an outpatient setting
within the framework of the Program the following is provided:
the right to choose a medical organization and attending physician (general practitioner, local physician, pediatrician, local pediatrician, general practitioner (family doctor) or paramedic);
the ability to make an appointment with a doctor and conduct diagnostic and laboratory research for the sick. Registration is made in the registries of medical organizations upon personal request from the patient or through the “Electronic Registration” information system of the medical organization;
the possibility of treatment in the day hospital of medical organizations in the region if the patient has indications in the direction of the attending physician;
the ability to call a local doctor at home if the patient is unable to visit a medical organization for health reasons;
the possibility of receiving primary specialized health care on the referral of a local physician, a local pediatrician, a general practitioner (family doctor), a medical specialist, or in the event of a citizen’s independent appeal to the medical organization to which he is attached, taking into account the procedures for providing medical care.

Primary and primary specialized health care in outpatient settings is provided:
1) insured citizens upon presentation of a compulsory medical insurance policy and an identity document;
2) children from the day of birth to the day of state registration of birth upon presentation of the compulsory medical insurance policy of the mother or other legal representatives and an identification document.

Primary health care is provided by general practitioners, local physicians, pediatricians, local pediatricians, and general practitioners (family doctors). The scope of diagnostic and therapeutic measures, the need for consultations with medical specialists for a particular patient is determined by the attending physician.

Extraordinary admission of patients served on a paid basis is not allowed.
Treatment and examination at home of patients who, due to health conditions and the nature of the disease, cannot visit medical organizations, are carried out as prescribed by the attending physician.

Primary specialized health care in an outpatient setting is provided upon the direction of the attending physician. The referral must be drawn up in accordance with regulatory documents with a mandatory indication of the purpose of the consultation and contain the results of a preliminary study in accordance with the profile of the consultation. Primary specialized health care at home is provided by referral from the attending physician.

Laboratory and instrumental methods studies are provided to citizens upon referral from their attending physician if there are medical indications, taking into account the procedures for providing medical care.

In medical organizations that provide primary specialized health care in an outpatient setting in a planned manner, a waiting list for the provision of primary specialized medical care in a planned form is maintained and citizens are informed in an accessible form, including using the Internet information and communication network, on the waiting period for the provision of primary specialized health care in an outpatient setting in a planned manner, taking into account the requirements of the legislation of the Russian Federation on personal data. The specified procedure does not apply to the provision of emergency or emergency medical care.

If there are medical indications for consultation with a medical specialist and (or) laboratory and diagnostic studies, absent in this medical organization, the patient must be referred to another medical organization participating in the Program.

Conditions and procedure for providing emergency, including specialized emergency medical care

Ambulance, including specialized emergency medical care, is provided to citizens in case of illness,
accidents, injuries, poisoning and other conditions requiring urgent medical intervention. Ambulance, including specialized ambulance, medical care by medical organizations of the state and municipal healthcare systems is provided to citizens of the Russian Federation and other persons free of charge.

Ambulance, including specialized emergency medical care, is provided in an emergency or emergency form outside of medical organizations, as well as in outpatient and inpatient settings.

The reasons for calling an ambulance in an emergency are:
a) disturbances of consciousness that pose a threat to life;
b) breathing problems that pose a threat to life;
c) disorders of the circulatory system that pose a threat to life;
d) mental disorders accompanied by the patient’s actions that pose an immediate danger to him or other persons;
e) sudden pain syndrome that poses a threat to life;
f) sudden dysfunction of any organ or organ system that poses a threat to life;
g) injuries of any etiology that pose a threat to life;
h) thermal and chemical burns posing a threat to life;
i) sudden bleeding that poses a threat to life;
j) childbirth, threat of termination of pregnancy;
k) the threat of an emergency, provision of emergency medical care and medical evacuation when eliminating the health consequences of an emergency.

Reasons for calling an ambulance in an emergency are:
a) sudden acute diseases(conditions) without obvious signs of a threat to life, requiring urgent medical intervention;
b) sudden exacerbations of chronic diseases without obvious signs of a threat to life, requiring urgent medical intervention;
c) declaration of death (except for the opening hours of medical organizations providing medical care on an outpatient basis).

When providing emergency medical care, if necessary, medical evacuation is carried out, which is the transportation of citizens in order to save lives and preserve health (including persons being treated in medical organizations that do not have the ability to provide the necessary medical care for life-threatening conditions, women during pregnancy, childbirth, the postpartum period and newborns, persons affected by emergencies and natural disasters).

Medical evacuation is carried out by mobile emergency medical teams, carrying out medical care measures during transportation, including the use of medical equipment.

Providing medical care to sick and injured people who seek help directly at the emergency medical care station (department) is provided in the office for receiving outpatients.

The absence of a compulsory medical insurance policy and identification documents is not a reason for refusal to call and provide emergency medical assistance.

Conditions and procedure for providing palliative care

Palliative care involves the provision of medical, social, psychological assistance
patients with various severe chronic progressive diseases with a terminal stage of the disease in order to provide the necessary pain therapy, medical and social assistance, care, psychosocial rehabilitation, as well as psychological and social support for relatives.

Palliative medical care is provided to citizens taking into account the procedures for providing medical care in an outpatient setting (not providing round-the-clock medical observation and treatment), in a day hospital (in conditions providing medical observation and treatment during the day, not requiring round-the-clock medical observation and treatment) and hospital (in conditions that provide round-the-clock medical supervision and treatment).

Palliative care is provided to patients by health professionals who have been trained to provide such care.

The volume of medical care provided under the Program in accordance with the legislation of the Russian Federation on compulsory medical insurance

The volumes of medical care by type, conditions and forms of its provision in general for the compulsory medical insurance program are:
for emergency medical care outside a medical organization, including medical evacuation - 321,215 calls;
for medical care in an outpatient setting, provided for preventive and other purposes (including visits to health centers, visits in connection with medical examinations, visits to nursing staff) - 2,325,122 visits;
for outpatient medical care provided
in an emergency form, – 500,126 visits;
for outpatient medical care provided in connection with diseases - 1,965,911 calls;
for medical care in conditions day hospitals– 565,115 patient days;
for specialized medical care in inpatient conditions - 176,123 cases of hospitalization (including 1,383 cases of high-tech medical care financed by compulsory medical insurance funds, 33,660 bed days in the “Medical Rehabilitation” profile and 1,909 cases of hospitalization at the expense of rationed funds insurance stock in accordance with Decree of the Government of the Russian Federation dated May 22, 2015 No. 493 “On approval of the Rules for the allocation in 2015 of funds from the normalized insurance stock of the Federal Compulsory Medical Insurance Fund for additional financial support for the provision of specialized medical care by federal government institutions”).

Outpatient doctor's appointment

The provision of outpatient medical care is carried out on a territorial basis. The procedure for organizing outpatient appointments in municipalities providing outpatient care provides for:

Extraordinary provision of outpatient care without prior appointment, regardless of the territorial principle, to all those who apply for emergency indications;

Availability of a queue when patients regularly apply for appointments with a doctor, diagnostic tests, consultations with specialists.

The operating hours of the medical department, the organization of appointments (pre-registration and various types of self-registration of patients for outpatient appointments), the schedule of doctors' appointments, the procedure for calling a doctor at home (indicating the telephone numbers by which doctor's house calls are registered, convenient operating hours of the reception desk) are regulated by internal work rules MO approved in accordance with the established procedure.

For outpatient clinics, it is recommended to establish a uniform operating hours from 8.00 to 20.00. At feldsher-midwife stations, if there is one specialist position, a working day is introduced with the shift divided into parts (with a break in work of more than 2 hours and additional pay) to be able to receive patients in the morning and evening hours.

Medical records of an outpatient patient (hereinafter referred to as the outpatient record) are stored in the medical institution providing outpatient care at the place of residence.

Medical care at home

Medical care at home is provided when the patient is unable to visit a medical facility providing outpatient care:

for health,

according to epidemiological indications.

In addition, at home the following is carried out:

patronage of children under 1 year of age;

observation until recovery of children under 1 year of age;

observation of children with infectious diseases until recovery;

patronage (active calls) by medical workers (doctor, nurse, paramedic) of patients with limitations in independent movement.

House calls must be made by a healthcare professional on the day the patient calls.

Medical care in a day hospital

In the day hospital, medical care is provided to patients if they need complex treatment using modern medical technologies, including a course of infusion therapy, therapeutic and diagnostic manipulations on an outpatient basis in the absence of the need for round-the-clock medical supervision.

The patient is referred for treatment in a day hospital by the attending physician.

The day hospital provides:

Bed space for the period of treatment;

Medicines in accordance with the List of Vital and Essential medicines and medical products necessary for the provision of inpatient medical care, as well as ambulance and emergency medical care (Appendix No. 4 to the Program) at the expense of the Ministry of Defense;

Physiotherapeutic procedures;

Examinations and consultations with specialists.

The criterion for completing a stay in a day hospital is the availability of the possibility/need for treatment at other stages (during outpatient admission, in a 24-hour hospital).

Medical care in hospital at home

In a hospital, medical care is provided to patients at home if, in the absence of the need for round-the-clock medical supervision, the patient’s condition does not allow him to visit the clinic, and home conditions (social, material, moral) allow him to organize the necessary care for the patient at home.

The decision on inpatient treatment at home is made by the attending physician in consultation with the head of the clinic department.

Medicines are provided in accordance with the List of vital and essential medicines and medical products necessary for the provision of inpatient medical care, as well as ambulance and emergency medical care (Appendix No. 4 to the Program) at the expense of the Ministry of Defense, as well as at the expense of personal funds citizens, with the exception of drug provision for persons with benefits established by the legislation of the Russian Federation and the Republic of Karelia.

The criterion for completing a stay in a day hospital is the availability of the possibility/need for treatment at other stages (outpatient treatment, 24-hour hospital stay).

Procedure and conditions for providing medical care in hospitals

Medical care in hospitals 24 hours a day

Medical care in 24-hour hospitals can be planned and emergency.

Indications for emergency hospitalization are life-threatening conditions that require emergency medical care in a 24-hour hospital setting.

For emergency indications, patients are hospitalized by referral from a doctor/paramedic of the emergency medical service and specialists from the Ministry of Defense, as well as upon self-referral.

Indications for planned hospitalization are conditions that require diagnostic and therapeutic measures in a 24-hour hospital setting, the implementation of which can be delayed. The waiting time for planned hospitalization cannot exceed 30 days.

Planned hospitalization is carried out on the direction of the attending physician.

The patient's nutrition, therapeutic and prophylactic manipulations, and drug provision are provided from the moment of admission to the hospital. Patients are accommodated in wards for 4 - 8 people.

The criteria for completing the stay at the stage of round-the-clock treatment are clinical recovery or improvement in the patient’s condition, in the absence of the need for round-the-clock medical supervision.

One of the parents (another legal representative) or another family member is given the right, in the interests of the child’s treatment, to stay with him in the hospital during the entire period of his stay, regardless of the child’s age.

When children are hospitalized, regardless of age, if there are medical indications for individual care, the mother is provided with a bed and food according to established standards.

Medical care in day hospitals

Hospitalization in a day hospital is carried out to provide medical care to patients who do not need round-the-clock medical supervision.

Referral to a day hospital is carried out by the attending physician.

Medicine provision for patients in a day hospital is carried out at the expense of the Ministry of Defense.

The criterion for completing a stay in a day hospital is the availability of the possibility/need for treatment at other stages (outpatient, in a 24-hour hospital).

The patient's nutrition, therapeutic and prophylactic manipulations, and medication provision are provided from the moment of admission to the day hospital.

Conditions and procedure for provision

emergency medical services

Emergency medical care is provided by emergency medical services stations and departments to residents of the Republic of Karelia and other persons located on its territory, free of charge, around the clock in case of conditions that threaten human life or health, caused by sudden illnesses, exacerbations of chronic diseases, accidents, injuries and poisonings, complications pregnancy and childbirth.

Calls are serviced as they arrive. The time allotted for servicing a call is determined by current regulations. In the absence of the required number of free teams, the order of servicing calls is determined by their significance. Ambulance teams are not involved in delivering patients from the Moscow Region home, systematically treating patients, or carrying out treatment procedures prescribed by Moscow Region doctors providing outpatient care.

Conditions and procedure for providing medical care

outside the Republic of Karelia

In cases where specialized, including high-tech medical care cannot be provided in medical organizations of the republic, the issue of the advisability of sending the patient for treatment outside the republic to federal healthcare institutions is decided.

The decision on the need for referral is made by the commission of the Ministry of Health and Social Development of the Republic of Karelia for the selection and referral of patients for treatment outside the republic. The list of federally subordinate healthcare institutions is determined by a joint order of the Ministry of Health and Social Development of the Russian Federation and the Russian Academy of Medical Sciences.

Appendix No. 3 to the Program (abbreviated)

implementation of the right of extraordinary provision of medical care established by the legislation of the Russian Federation

Republic of Karelia and municipalities

1. This Procedure determines the rules for the extraordinary provision of medical care under the Program in healthcare institutions of the Republic of Karelia to disabled people of the Great Patriotic War and other categories of citizens specified in Articles 14-19 and 21 of the Federal Law of January 12, 1995 No. 5-FZ “On Veterans” ( hereinafter referred to as citizens).

2. Extraordinary provision of medical care to citizens is carried out if citizens have medical indications.

3. Outpatient medical and inpatient medical care is provided to citizens on an extraordinary basis by medical organizations at the place of residence or work to which they were attached during the period of work before retirement (hereinafter referred to as territorial medical organizations) upon presentation of a document confirming membership in a preferential category of citizens , and includes:

Extraordinary receipt of a coupon for outpatient appointments and provision of outpatient medical care on an extraordinary basis;

Extraordinary provision of inpatient medical care;

Extraordinary diagnostic studies.

4. The referral of citizens to the state health care institution of the Republic of Karelia to provide them with emergency medical care is carried out on the basis of the conclusion of the medical commission by the territorial medical organization with a detailed extract from the medical documentation and indicating the purpose of the referral.

Appendix No. 4 to the Program (abbreviated)

SCROLL

vital and essential medicines

and medical products necessary to provide

inpatient medical care, as well as ambulance and emergency medical care

The document has become invalid or cancelled.

Order of Rosstat dated September 4, 2015 N 412 “On approval of statistical tools for organizing federal statistical observation in the field of healthcare by the Ministry of Health of the Russian Federation”

Section III. Activities of a medical organization to provide medical care in an outpatient setting

A visit is a contact of a patient with a doctor of a medical organization or unit providing medical care on an outpatient basis for any reason, followed by an entry in the “Medical record of a patient receiving medical care on an outpatient basis” (form N 025/u), including complaints, anamnesis , objective data, diagnoses: main, background, competing and concomitant diseases, injuries, poisonings with their ICD-10 codes, health group, prescribed treatment, examination, as well as the results of examination and follow-up.

The following visits are subject to recording:

Doctors of any specialties who provide outpatient appointments, including consultative appointments (therapists, pediatricians, surgeons, obstetricians-gynecologists, urologists, otolaryngologists, etc., including heads of departments), in medical organizations and outside medical organizations;

Doctors of emergency medical care points (departments) at home;

Doctors at health centers, shop therapists, obstetricians-gynecologists and others who provide outpatient appointments at health centers during hours specially allocated for outpatient appointments;

Doctors providing medical care on specially designated days for appointments on an outpatient basis, when traveling to other medical organizations ( district hospitals, district hospitals, outpatient clinics, paramedic and obstetric centers);

Psychotherapists during group sessions (the number of visits is taken into account according to the number of patients studying in the group);

Visiting a patient or a patient's relative to refill a prescription (for malignant neoplasms, diabetes mellitus and other diseases);

Infectious disease doctors conducting door-to-door visits during an outbreak of infectious diseases, examining contacts in the outbreak (family) of an infectious disease;

Consultations of patients on an outpatient basis by doctors of a unit providing medical care in an inpatient setting, for registration of which the “Coupon for a patient receiving medical care on an outpatient basis” (hereinafter referred to as the Coupon) (f. N 025-1/u) is filled out separately for each specialty of the doctor ;

Cases of providing medical care in the emergency departments of medical organizations to patients who are not subject to hospitalization, for the recording of which, in addition to recording in the “Register of admission of patients and refusals of medical care in inpatient conditions” (f. N 001/u), a coupon is filled out;

Consultations by doctors of a unit providing medical care on an outpatient basis to patients undergoing treatment in units providing medical care in an inpatient setting.

Preventive examinations of children in nurseries preschool institutions, schools, preventive examinations the population, including periodic examinations of workers of industrial enterprises, employees of other enterprises (institutions), regardless of whether they were carried out within the walls of a unit providing medical care on an outpatient basis, or directly at enterprises (institutions);

To the doctors of the draft commissions.

Visits by a patient to the same doctor during the day are counted as one visit.

The following are not counted as doctor visits:

Cases of medical care provided by emergency medical service station (department) personnel;

Examinations in X-ray rooms, laboratories and other auxiliary departments (offices);

Cases of medical care during physical education classes, educational and sports events;

Consultations and examinations conducted by medical commissions (MC) in accordance with Article 48 of the Federal Law of November 21, 2011 N 323-FZ “On the fundamentals of protecting the health of citizens in the Russian Federation”;

Visits to doctors in auxiliary departments (offices), with the exception of cases of “management” of the patient by the doctor of these departments (offices): prescription of treatment with an entry in the primary medical documentation, monitoring and dynamics of the patient’s condition during and after completion of the course of treatment (radiation, physiotherapy and etc.).

Medical visits include:

Visits when the patient is diagnosed with diseases classified in ICD-10 classes I - XX;

Visits to adjust treatment;

Visits to patients under dispensary observation during the period of remission;

Visits to patients in connection with registration of a sanatorium-resort card at MSEC, opening and closing a certificate of incapacity for work, obtaining a certificate of illness of a child, referral for an abortion for medical reasons, regarding pregnancy pathologies, after abortions for medical reasons, as well as for consultations with specialists, if the doctor has established a diagnosis in his specialty.

Preventive visits include conditions classified in class XXI of ICD-10.

If intern doctors conduct appointments under the guidance of a specialist doctor and in his presence, then information about visits is taken into account only in the line corresponding to the position of the specialist doctor.

In cases where interns independently see patients, the information is shown in line 122, regardless of the specialty in which the doctor is undergoing internship.

Visits to doctors in auxiliary departments and offices ( radiation therapy, physiotherapeutic, physical therapy, endoscopy, functional diagnostics, etc.) are not taken into account in table 2100. The work of auxiliary departments and offices is shown in the corresponding tables of the Form.

Table 2106 shows requests for diseases, injuries, poisoning and some other consequences of external causes (ICD-10 codes: A00 - T98), as well as for preventive and other purposes (ICD-10 codes: Z00 - Z99).

An appeal includes one or more visits to a patient, as a result of which the purpose of the appeal is achieved.

An appeal as a complete case in primary health care and primary specialized health care is one appeal and one or more visits to the patient, as a result of which the purpose of the appeal is achieved. If the purpose of the appeal is not achieved and the Ticket is closed, the case is considered not completed.

Information for table 2400 “Maternity care at home” is taken from the “Logbook of recording obstetric care at home” (registration form N 032/u).

Table 2402. To fill out lines 6 and gr. 3 use “Medical death certificates” (registration form N 106/u-08). Acute disorders cerebrovascular accident (codes 160 - 164) and myocardial infarction (codes 121 - 122) are included in table 2402 only if they are selected as the underlying cause of death. A medical organization reports only on death certificates issued by this medical organization.

Table 2510. Information about those subject to and examined during medical examinations includes by category: children 0 - 14 years old inclusive (of which: up to 1 year), children 15 - 17 years old inclusive and adult population(18 years and older), examined in accordance with periodic (order of the Ministry of Health and Social Development of Russia dated April 12, 2011 N 302n, registered with the Ministry of Justice of the Russian Federation on October 21, 2011 N 22111) and other medical examinations.

Table 2510 is filled out only by those medical organizations that organize the examination of the relevant contingents and are responsible for its implementation, and is not filled out by specialized (dermatovenerological, anti-tuberculosis, etc.) organizations that may take part in this work.

Those to be inspected and inspected include: individuals only once a year, regardless of how many times a year they were subject to inspection and were inspected. The planned numbers of those subject to examination by category are approved by order of the head of the medical organization and adjusted at the end of the reporting period. The number of those examined must be equal to the number of those subject to inspection or be less than this number.