Просмотров: 3 379

MEDICAL PASSPORT OF RHEUMATIC PATIENT (MPRP). STANDARD GUIDELINES ON FILLING OUT AND COMMENTS. FILL OUT THE MEDICAL PASSPORT WITHOUT ASSISTANCE

The author introduces an individual medical documentation form for a rheumatic patient, the Medical Passport of Rheumatic Patient (MPRP). It includes general essential information about primary conditions, vaccination, allergic reactions, blood transfusion, and surgical interventions. Information about rheumatological pathology covers a detailed diagnosis, a drug therapy section, containing data about basic, disease-modifying, genetically engineered biological drugs, glucocorticoids, with specification of dose and duration of treatment. Place and date of hospital admission are also specified. The MPRP is a patient’s document intended for a treating physician. Introduction of the MPRP will increase accuracy of medical information, improve the process of anamnesis development, improve relationships between a patient and a doctor, increase patient adherence to treatment, insure consistency in work of health care institutions. Key words:  rheumatology, rheumatic diseases, health care organisation, outpatient care, inpatient care, medical documentation, new form of medical documentation, individual medical documentation, patient’s medical record, Medical Passport of Rheumatic Patient, guidelines on filling out the Medical Passport of Rheumatic Patient, comments to the Medical Passport of Rheumatic Patient, MPRP. Introduction. Nowadays informatisation processes are widely introduced to the medical sphere globally. As a result, national registers are being organised for rheumatic patients. At the same time, there are no individual programs for a particular patient, except standard medical documentation. In order to increase efficiency and accuracy of individual medical information, we suggest introduction of the Medical Passport of Rheumatic Patients. This passport can be issued in hard copy, prepared in the electronic format or recorded on a plastic card. The contents of the Medical Passport have a universal character and do not depend on the principles of health care organisation in any country of the world. It can be used both by physicians in private practices and by doctors of state hospitals. Use of the Passport is possible both for outpatient and inpatient care, in the developed and developing countries of the world. The Medical Passport of Rheumatic Patient (MPRP) contains a passport section, signal signs, data of follow-up monitoring, and information about concomitant diseases with dates of diagnosis. The medical passport is based on the best practices in keeping medical records of the USSR health service developed under the conditions of working with million population cohorts, significant geographical distances, a large number of health institutions from outpatient clinics and rural district hospitals to multi-field hospitals with over 1,000 beds. Passport sections and their contents can be changed depending upon local conditions. However, we suggest obligatory introduction of purely rheumatologic data about treatment, particularly information on therapy with GEBDs (genetically engineered biological drugs), basic and disease-modifying drugs (lists to be determined by local regulations), as well as systemic osteoporosis treatment. Different forms (in hard copy, electronic format) of the Medical Passport of Rheumatic Patient can be found here: SAFETY AND CONFIDENTIALITY OF THE MEDICAL PASSPORT OF RHEUMATIC PATIENT (MPRP)
  1. Filling-out of the Medical Passport of Rheumatic Patient (MPRP) does not require preliminary registration.
  2. Filling-out of the MPRP form in hard copy guarantees full confidentiality.
  3. The electronic form of the MPRP does not save or pass any entered data to other websites, and does not count visitors.
Medical Passport Form The MPRP is available in hard copy and in the electronic format. The hard copy variant is available as forms of different sizes and as a notebook. Paper forms are available in sizes: А4, ¼ and 10.5х7.5 cm with two-sided printing. Sample of the A4 MPRP form. Паспорт бри 1 публ   Structure of the Medical Passport Form Passport Section. Signal Signs. Former (Follow-Up) Medical Monitoring.  Pharmaceutical Therapy of Rheumatic Diseases. Concomitant Diseases. Hospital Treatment.   General Guidelines on Filling Out It is better to keep with the recommended informatisation scheme to avoid overloading the document with secondary information. If needed, you can mark some sections with * and later discuss them in detail with your physician. Filling out of all lines in the MPRP is not obligatory. Amount of the specified information and entry of personal data are at a patient’s discretion.  Entry of different answer variants is unlimited. You do not need to have any special medical skills to fill out the MPRP, any educated person is able to do that. The MPRP is not intended to replace any existing official medical documentation. It is better to discuss the filled out MPRP with your physician, taking into account his/her comments and ideas.   Guidelines on Filling Out the Passport Section 1 This information is generally accepted and necessary in medical documentation. This section is intended to insure consistency in work of health care institutions. It is possible to enter a full name of a private doctor, a general practitioner, a family doctor, a group practice doctor, a doctor from an outpatient department (a cabinet, an early treatment clinic, a health centre), a doctor from a private or state hospital with contact phone numbers.   Guidelines on Filling Out the Signal Signs Section 2 Practically this section is similar to the Anamnesis Vitae section of the medical history. Anamnesis vitae is data specifying a patient’s physical, mental and social development provided in a certain sequence. Rules issued by a country’s Ministry of Health regulate use of notes about blood type and Rh blood group in passports and other identity documents.  The stamp is used for these purposes. In this case, it is possible to copy the information about blood type and Rh blood group from an ID document and to specify the date of entry. The Vaccination section shall be filled out based on a Vaccination Certificate (according to the national vaccination schedule).  This Certificate is issued by all health care institutions conducting vaccination and shall be kept by a vaccinated person.   Guidelines on Filling Out the Former (Follow-Up) Medical Monitoring Section 3 A Transfer Summary from a Patient’s Medical Documentation is an insert intended for entry information about former examination and treatment of a patient before the patient turned for medical assistance to a certain specialist or to a certain health care institution. If it is impossible to obtain any former medical records, information about clinical events, it is sufficient to tell this information to your doctor during your visit. The primary disease diagnosis is a rheumatologic diagnosis that can be provided in detail, as it is written in a hospital discharge summary. Date of diagnosis shall be mentioned.   Guidelines on Filling Out the Pharmaceutical Therapy of Rheumatic Diseases Section PHARMACEUTICAL THERAPY OF RHEUMATIC DISEASES——————————————————————————————————————————————————— Describe the use of drugs from the list*. *According to national recommendations  Suggested List of Drugs Used in Rheumatology GEBDs (genetically engineered biological drugs) Basic and disease-modifying drugs: Sulfasalazine Methotrexate Leflunomide Penicillamine Cyclophosphamide Chlorambucil Azathioprine Antimalarials (Delagil, Plaquenil, Immard) Mycophenolate mofetil   Systemic osteoporosis treatment   Glucocorticoids. Dose. Duration.   Guidelines on Filling Out the Concomitant Diseases Section 4 A disease detected first time is considered newly diagnosed. Diseases that can re-occur several times (sore throat, flue, ARD, pneumonia, injuries, etc.) are considered newly diagnosed each time. All chronic diseases are entered with the dates of their detection. If a patient wants, it is possible to include recurring acute conditions or to inform your doctor about them, if they repeat several times a year.   Guidelines on Filling Out the Hospital Admission (Inpatient Care, Hospital Treatment) Section 5 Here you specify dates and place of hospital treatment due to rheumatologic disease, rheumatologic and orthopedic surgery or endoprosthetic replacement. It is better to have a hospital discharge summary with you visiting your doctor. What are the advantages of the medical passport in real life? For a patient: It gives a patient an opportunity of having his/her “own” medical history in hand. Filling out of a MPRP allows systematisation of the conducted examination and treatment of the disease. The Signal Signs Section will be helpful in any real life situation. Besides, it extends the time spent communicating with your doctor. For a doctor: Increase in accuracy of medical information. Improvement of the process of anamnesis development. Extending time spent communicating with a patient and conducting a physical examination. Strengthening the ties between a patient and a doctor. Increase in patient adherence to treatment. A doctor from any health care institution has an access to essential and complete information about a patient. The MPRP allows improvement of consistency in work of various health care institutions until the moment, when a uniform electronic medical history is introduced into routine practice.   Discussion. Introduction of a new self-regulatory form at first can result in a negative reaction from medical workers, who have to prepare reporting documents for insurance companies. However, primary time expenditures on filling out a medical passport will be compensated by increase in accuracy of medical information.  It will reduce the time and simplify the process of medical anamnesis development, if it is possible to attach a copy of a patient’s medical passport to a medical history. The ties between a patient and a doctor will be stronger. A patient’s adherence to treatment will increase. It will gain and improve consistency in work of various health care institutions. The MPRP is in line with patients’ intentions, as some of them have been describing their conditions themselves at random for a long time already. Patients register their visits to health care institutions, results of major examinations, print this data and present this to a doctor. The Medical Passport of Rheumatic Patient shall not in any way substitute a traditional real time communication of a patient and a doctor, but it makes this communication more person-oriented, both for a patient and a doctor.  The MPRP will partially solve the issue connected with patients’ wish to have in hand their medical documentation about their health.   Conclusion. The team of the Visual Rheumatology website wishes all of you good health.