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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)
- Filling-out of the Medical Passport of Rheumatic Patient (MPRP) does not require preliminary registration.
- Filling-out of the MPRP form in hard copy guarantees full confidentiality.
- The electronic form of the MPRP does not save or pass any entered data to other websites, and does not count visitors.