Rules for filling out form 088 y 06. Sample Completed referral to ITU: F07.08 Organic personality disorder. Diagnosis when referring to a medical and social examination

Filling out the document using a computer allows you to increase, if necessary, the number of lines in the paragraphs of the form, to avoid the use of inserts

In the work of the bureau of medical and social expertise, it is of great importance that the doctor of the health facility correctly fill out the form No. 088 / y-06 "Referral for medical and social expertise by an organization providing medical and preventive care", approved by order of the Ministry of Health and Social Development of Russia dated January 31, 2007 No. 77.

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Correct completion of the form No. 088 / y-06

After the cancellation of registration form No. 088 / y-97 "Referral for medical and social examination" and the instructions regulating the procedure for filling it out, approved by the Ministry of Health of Russia dated December 15, 1999 No. 06-23 / 6-20, the corresponding instructions for filling out a new registration form No. 088 / y-06 "Submission for medical and social examination by an organization providing medical and preventive care" (hereinafter - form No. 088 / y-06) was not issued.

now >>

Meanwhile, despite the fact that each item of the form No. 088 / y-06 is accompanied by explanations, this is often not enough. The existing stereotypes of the activities of employees (hereinafter referred to as ITU) sometimes become the reason for making unreasonable demands when receiving documents from citizens for examination at the ITU bureau and a reason for refusing to register documents.

Most of our patients, having received the form No. 088 / y-06, were examined at the place of residence (registration). An analysis of the actions of specialists from individual ITU bureaus in various regions of Russia showed that their requirements for filling out form No. 088 / y-06 reflect the desire to follow the canceled instructions.

So, it is often indicated that it is necessary to stamp the institution on the title page of the document. Also, employees of some ITU bureaus require, as a mandatory requirement, that each of the specialists (in addition to the attending physician) fill out clause 23 "State of a citizen when sent for a medical and social examination" - indicating the data of the examination and diagnosis.

Meanwhile, when filling out clause 24 "Results of additional research methods", it is not required that each specialist doctor personally enter the results of laboratory, radiological, endoscopic, functional, ultrasound, cytological, neurofunctional and other studies carried out on his instructions, although the results of these studies depends .

In our opinion, the data of studies and examinations conducted by doctors of other specialties can be transferred to form No. 088 / y-06 from the medical history by the attending physician. Nevertheless, we have a considerable number of examples when referrals to the ITU were not accepted for implementation, since paragraph 23 lacked the signatures of the relevant specialists and their personal seals.

Filling out the registration form No. 088 / y-06 on a computer

Filling out a document using a computer allows you to:

1. increase, if necessary, the number of lines in form items;
2. avoid using inserts (stretch text);
3. save direction format;
4. do not certify with signatures and seals additional insert sheets.

ITU denials

In order to prevent in the conduct of ITU, improve its results, which depends, among other things, on the correct filling out of form No. 088 / y-06, the requirements for its execution should be logical, and the understanding of the content of each paragraph should be the same for all performers. This is all the more necessary, since at present there is no officially announced procedure for filling out this document.

The current order of the Ministry of Health and Social Development of Russia dated 08/01/2007 No. 514 "On the Procedure for issuing sick leave certificates by medical organizations" is only the basis for issuing form No. 088 / y-06 and applies mainly to working citizens. In relation to non-working persons, pensioners who repeatedly apply to confirm their disability group, there is no fundamental document.

At the Main Military Clinical Hospital named after N.N. Burdenko (hereinafter referred to as the hospital) has been operating a medical information system (MIS) for more than 25 years. It is an integral part of the structures that ensure the clinical and economic activities of the institution. The use of modern information technologies is one of the priorities of the hospital and allows to increase the efficiency of processing and obtaining information in the process of diagnosing and treating patients, save time spent by staff on maintaining records and preparing reporting materials.

In the process of building such a system, various options for using computer technology were tested. As the most appropriate for the tasks set, a variant of the implementation of the system based on personal computers united in local networks was chosen.

In the hospital for the past 15 years, referral of patients to the ITU has been carried out using personal computers, which are equipped with all medical and diagnostic departments. Information is concentrated in the case history, where data from related specialists are included. Such opportunities allowed to increase the efficiency of processing medical information, and the quality of work improved.

Refusals to servicemen in the form No. 088 / y-06

In addition to the above, I would like to draw your attention to the fact that some ITU bureaus refuse to accept documents for examination by military personnel who have not yet been dismissed from service, but who have passed an examination by a military medical commission. This is a violation of the Federal Law of March 28, 1998 No. 52-FZ "On Compulsory State Insurance of Life and Health of Military Personnel, Citizens Called for Military Training, Individuals and Commanders of the Internal Affairs Bodies of the Russian Federation, the State Fire Service, and Bodies for Controlling the Turnover narcotic drugs and psychotropic substances, employees of institutions and bodies of the penitentiary system.

At the time when the above-mentioned Federal Law was adopted, the letter of the Ministry of Labor of Russia dated November 10, 1997 No. 5546-AO was in force, according to which no examination of military personnel who were not dismissed from service was carried out in ITU institutions. Since the letter of the Ministry of Labor of Russia did not comply with the law, this document was withdrawn by letter of the Ministry of Health and Social Development of Russia dated 07.02.2006 No. 544-VS. We consider it necessary to include the text of this letter in the appendix, since, apparently, the employees of the ITU bureau are not aware of it in all regions of Russia. For this reason, it is necessary to issue a copy of this letter to those patients who were refused acceptance of documents for examination at the ITU Bureau.

Application

Letter of the Ministry of Health and Social Development of Russia dated February 7, 2006 No. 544-VS “On the withdrawal of the letter of the Ministry of Labor of Russia dated November 10, 1997 No. 5546-AO”

The Ministry of Health and Social Development of the Russian Federation, in connection with numerous appeals regarding the application of the letter of the Ministry of Labor of Russia dated November 10, 1997 No. 5546-AO, according to which the examination of military personnel in institutions of medical and social expertise, reports the following.

After the introduction of this letter into the practice of the activities of institutions of medical and social expertise, the Federal Law of March 28, 1998 No. 52-FZ "On Compulsory State Insurance of Life and Health of Military Personnel, Citizens Called for Military Training, Individuals and Commanders of Internal Affairs Bodies" was adopted. affairs of the Russian Federation, employees of institutions and bodies of the penitentiary system and employees of the federal tax police" according to which an insured event in the implementation of compulsory state insurance is, among other things, the establishment of a disability for the insured person during the period of military service, service, military training or before the expiration of one years after dismissal from military service, from service, after the end of military training due to injury (wounds, injuries, concussions) or diseases received during military service, service, military training (Article 4).

According to paragraph 3 of the List of documents required to make a decision on the payment of the sum insured to military personnel insured under compulsory state life and health insurance, citizens called up for military training, private and commanding personnel of the internal affairs bodies of the Russian Federation, the state fire service, bodies for monitoring turnover of narcotic drugs and psychotropic substances, employees of institutions and bodies of the penitentiary system and employees of the federal tax police, approved by Decree of the Government of the Russian Federation of July 29, 1998 No. 855, in the event that the insured person is found to have a disability during the period of military service, service, military dues, the insured person provides a copy of the certificate confirming the fact of the establishment of disability to the insured person, issued by the institution of medical and social expertise.

The Federal Law of November 24, 1995 No. 181-FZ "On the Social Protection of Disabled Persons in the Russian Federation" (with further amendments and additions) and the regulatory legal documents issued for the purpose of its implementation also do not see any restrictions for military personnel to undergo a medical and social examination.

Thus, the letter of the Ministry of Labor of Russia dated November 10, 1997 No. 5546-AO does not comply with the changed legislation, under which military personnel have the right to undergo an examination in federal state institutions of medical and social expertise.

In this regard, the Ministry of Health and Social Development of the Russian Federation withdraws the letter of the Ministry of Labor of Russia dated November 10, 1997 No. 5546-AO.

Bring this letter to all federal state institutions of medical and social expertise.

IN AND. Starodubov, Deputy Minister

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1 MINISTRY OF HEALTH AND SOCIAL DEVELOPMENT OF THE RUSSIAN FEDERATION ORDER of January 31, 2007 N 77 On approval of the form for referral for medical and social examination by an organization providing medical and preventive care (as amended on October 28, 2009) Document with amendments made by: order of the Ministry of Health and Social Development of Russia dated October 28, 2009 N 853n (Rossiyskaya gazeta, N 232,) (entered into force on January 1, 2010). In accordance with the Decree of the Government of the Russian Federation of February 20, 2006 N 95 "On the procedure and conditions for recognizing a person as disabled" (Collected Legislation of the Russian Federation, 2006, N 9, Art. 1018) I order: for a medical and social examination by an organization providing medical and preventive care" according to the appendix. Minister M. Zurabov Registered with the Ministry of Justice of the Russian Federation on March 12, 2007, registration N 9089 Appendix. Form N 088 / y-06. Referral for medical and social examination by an organization providing medical and

2 preventive care Supplement to the order of the Ministry of Health and Social Development of the Russian Federation of January 31, 2007 N 77 (as amended, entered into force on January 1, 2010 by order of the Ministry of Health and Social Development of Russia of October 28, 2009 N 853n, - see the previous edition) Medical documentation Form N 088 / y-06 Ministry of Health and Social Development of the Russian Federation (name and address of the organization providing medical and preventive care) REFERRAL FOR MEDICAL AND SOCIAL EXAMINATION BY THE ORGANIZATION PROVIDING THERAPEUTIC AND PREVENTIVE CARE Date of issue " " 20*

3 1. Surname, name, patronymic of the citizen sent for medical and social examination (hereinafter referred to as the citizen): 2. Date of birth: 3. Gender: 4. Surname, and my name, patronymic of the legal representative of the citizen (to be filled in if there is a representative) : legal 5. Address of the place of residence of the Citizen (in the absence of a place of residence, the address of stay, actual residence on the territory of the Russian Federation is indicated): 7. Excluded 8. The degree of loss of professional ability to work in percent:

4 (to be filled in upon re-sending) 9. Sent initially, re-sent (underline as necessary). 10. Who works at the time of sending for a medical and social examination (indicate the position, profession, specialty, qualifications and length of service in the specified position, profession, specialty, qualifications; for non-working citizens, make an entry: "does not work") 11. Name and address of the organization in which the citizen works: 12. Conditions and nature of the work performed: 13. Main profession (specialty): 14. Qualification in the main profession (class, rank, category, rank):

5 15. Name and address of educational institution: 16. Group, class, course (underline to be indicated): 17. Profession (specialty) for which training is provided: 18. Observed in organizations providing medical and preventive care since a year. 19. History of the disease (beginning, development, course, frequency and duration of exacerbations, medical and recreational and rehabilitation measures taken and their effectiveness):

6 (it is described in detail during the primary referral; during the second referral, the dynamics for the period between examinations is reflected, new cases of diseases detected during this period that led to persistent violations of body functions are described in detail) operations, diseases for which heredity is aggravated, in addition, in relation to the child, it is indicated how the mother's pregnancy and childbirth proceeded, the timing of the formation of psychomotor skills, self-service, cognitive-playing activities, skills of neatness and self-care, how early development proceeded (by age, lagging, ahead of schedule): (filled in during the primary referral) 21. Frequency and duration of temporary disability (information for the last 12 months): N Date (day, month, year) of the beginning of temporary disability incapacity for work Number of days (months and days) incapacity for work Diagnosis

7 22. The results of the measures taken for medical rehabilitation in accordance with the individual rehabilitation program for a disabled person (to be filled in upon re-referral, specific types of restorative therapy, reconstructive surgery, sanatorium treatment, technical means of medical rehabilitation, including prosthetics and orthotics, as well as the terms, to which they were provided; lists the functions of the body that could be compensated or restored in whole or in part, or a note is made that there are no positive results): other specialties):

8 24. Results of additional research methods (the results of laboratory, X-ray, endoscopic, ultrasound, psychological, functional and other types of research are indicated): 25. Body weight (kg), height (m), body mass index. 26. Assessment of physical development: normal, deviation (underweight, overweight, short stature, high stature) (underline as appropriate).

9 27. Evaluation of psychophysiological endurance: norm, deviation (underline as necessary). 28. Evaluation of emotional stability: norm, deviation (underline as necessary). 29. Diagnosis when referring to a medical and social examination: a) underlying disease code according to the ICD: b) underlying disease: c) concomitant diseases: d) complications: 30. Clinical prognosis: favorable, relatively favorable, doubtful (uncertain), unfavorable ( Underline whatever applicable).

10 31. Rehabilitation potential: high, satisfactory, low (underline as appropriate). 32. Rehabilitation prognosis: favorable, relatively favorable, doubtful (uncertain), unfavorable (underline as appropriate). 33. The purpose of the referral for a medical and social examination (underline as appropriate): to establish disability, the degree of loss of professional ability to work as a percentage, to develop (correct) an individual rehabilitation program for a disabled person (disabled child), a rehabilitation program for a victim of an accident at work and an occupational disease , for another (specify): 34. Recommended measures for medical rehabilitation for the formation or correction of an individual rehabilitation program for a disabled person (disabled child), a rehabilitation program for a victim of an accident at work and an occupational disease:

11 (specific types of rehabilitation therapy are indicated (including drug provision in the treatment of a disease that caused disability), reconstructive surgery (including drug provision in the treatment of a disease that caused disability), technical means of medical rehabilitation, including prosthetics and orthotics, a conclusion on the sanatorium - spa treatment with a prescription for the profile, frequency, duration and season of recommended treatment, the need for special medical care for persons injured as a result of accidents at work and occupational diseases, the need for medicines for the treatment of the consequences of accidents at work and occupational diseases, other types of medical rehabilitation) Chairman of the medical commission: (signature) (signature transcript) Members of the medical commission: (signature) (signature transcript) (signature) (signature transcript) (signature) (signature transcript) M.P. Cutting line

12 To be returned to the organization providing medical and preventive care that issued the referral for medical and social examination Return coupon (name of the federal state institution of medical and social examination and its address) social examination 4. Diagnosis of the federal state institution of medical and social examination: a) code of the underlying disease according to the ICD:

13 c) concomitant diseases: c**) complications: 5. Types of violations of body functions and their severity (according to the classifications approved by the order of the Ministry of Health and Social Development of Russia of August 22, 2005 N 535 (registered in the Ministry of Justice of Russia on September 13, 2005 N 6998): 6. Limitations of the main categories of life activity and the degree of their severity (according to the classifications and criteria approved by the order of the Ministry of Health and Social Development of Russia dated August 22, 2005 N 535):

14 7. Decision of the federal state institution of medical and social expertise: disability of the first, second, third groups was established, in the category "disabled child" (underline as necessary); cause of disability: degree of loss of professional ability to work in percent: date of re-examination: recommendations for medical rehabilitation: recommendations for professional, social, psychological and pedagogical rehabilitation:

15 8. Reasons for refusal to establish disability: 9. Date of sending the return coupon: " " 20. Head of the federal state institution of medical and social expertise (signature) (signature decoding) M.P. * Not later than one month from the date of issue, this referral can be submitted by a citizen (his legal representative) to the branch of the main bureau of medical and social expertise - the bureau of medical and social expertise. ** The numbering corresponds to the original. - Database manufacturer's note.

16 The version of the document, taking into account changes and additions, was prepared by Kodeks JSC

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Approve form N 088 / y-06 "Referral for medical and social examination by an organization providing medical and preventive care" in accordance with the appendix.

Minister
M.Yu. ZURABOV

Application
to the Order
Ministry of Health
and social development
Russian Federation
dated January 31, 2007 N 77

Medical documentation Form N 088/u-06 Ministry of Health and Social Development of the Russian Federation 28.10.2009 N 853н) Date of issue "__" _______ 20__<*> 1. Last name, first name, patronymic of the citizen sent for medical and social examination (hereinafter referred to as the citizen): ________________ __________________________________________________________________ 2. Date of birth: _______________________ 3. Sex: ________________ 4. Last name, first name, patronymic of the legal representative of the citizen (filled in if there is a legal representative ): _______________ 5. Address of the place of residence of a citizen (in the absence of a place of residence, the address of stay, actual residence on the territory of the Russian Federation is indicated): _____________________________ __________________________________________________________________ emphasize). Clause 7. - Deleted. (as amended by the Order of the Ministry of Health and Social Development of the Russian Federation of October 28, 2009 N 853n) 8. The degree of loss of professional ability to work in percent: __________________________________________________________________ (filled in when re-directed) 9. Sent initially, repeatedly (underline as necessary). 10. Who works at the time of sending for a medical and social examination _______________________________________________________ (indicate the position, profession, specialty, __________________________________________________________________ qualification and length of service in the specified position, profession, specialty, qualification; in relation to non-working citizens, make an entry: “does not work”) 11. Name and address of the organization in which the citizen works: _____________________________________________________________ __________________________________________________________________ 12. Conditions and nature of the work performed: _______________________ __________________________________________________________________ 13. Main profession (specialty): __________________________ 14. Qualification in the main profession (class, rank, category, rank): _______________________________________________________________ 15. Name and address of the educational institution: ____________ _______ ___________________________________________________________ __________________________________________________________________ 16. Group, class, course (underline to indicate): _______________ 17. Profession (specialty) for which training is provided: ______________________________________________________________ 18. Observed in organizations providing medical and preventive care since ____ years. 19. History of the disease (beginning, development, course, frequency and duration of exacerbations, therapeutic and rehabilitation measures taken and their effectiveness): examinations, describe in detail the new cases of diseases identified during this period that led to persistent violations of the body's functions) cations, diseases for which heredity is aggravated, in addition, in relation to the child, it is indicated how pregnancy and childbirth proceeded in the mother, the timing of the formation of psychomotor skills, self-service, cognitive-playing activities, skills of neatness and self-care, how early development proceeded (by age, lagging behind, ahead of)): __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ (filled in during the primary referral) 21. Frequency and duration of temporary disability (information for the last 12 months):

22. The results of the measures taken for medical rehabilitation in accordance with the individual rehabilitation program for a disabled person (to be filled in upon re-referral, specific types of restorative therapy, reconstructive surgery, sanatorium treatment, technical means of medical rehabilitation, including prosthetics and orthotics, as well as terms to which they were provided; lists the functions of the body that could be compensated or restored in full or in part, or a note is made that there are no positive results): __________________________________________________________________ 23. State of a citizen when referred for a medical and social examination (complaints, examination data by the attending physician and doctors of other specialties are indicated): __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ psychological, functional and other types of research): __________________________________________________________________ __________________________________________________________________ ____________________ ________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ 25. Body weight (kg) ____, height (m) _____, body mass index _____. 26. Assessment of physical development: normal, deviation (underweight, overweight, short stature, high stature) (underline as appropriate). 27. Evaluation of psychophysiological endurance: norm, deviation (underline as necessary). 28. Evaluation of emotional stability: norm, deviation (underline as necessary). 29. Diagnosis upon referral for a medical and social examination: a) underlying disease code according to the ICD: _____________________________ b) underlying disease: _______________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ c) concomitant diseases: ________________________________________________ __________________________________________________________________ __________________________________________________________________ d) complications: ___________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ (as amended by the Order Ministry of Health and Social Development of the Russian Federation of October 28, 2009 N 853n) 30. Clinical prognosis: favorable, relatively favorable, som negative (indefinite), unfavorable (underline as appropriate). 31. Rehabilitation potential: high, satisfactory, low (underline as appropriate). 32. Rehabilitation prognosis: favorable, relatively favorable, doubtful (uncertain), unfavorable (underline as appropriate). 33. The purpose of sending for a medical and social examination (underline as necessary): to establish disability, the degree of loss of professional ability to work in percent, to develop (correct) an individual rehabilitation program for a disabled person (disabled child), a rehabilitation program for a victim of an accident at work and occupational disease, for another (specify): _____________________________ __________________________________________________________________ __________________________________________________________________ (as amended by the Order of the Ministry of Health and Social Development of the Russian Federation of October 28, 2009 N 853n) as a result of an accident at work and an occupational disease: (as amended by the Order of the Ministry of Health and Social Development of the Russian Federation of October 28, 2009 N 853n) __________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ __________________________________________________________________ (indicate specific types of restorative therapy (including drug provision in the treatment of a disease that caused disability), reconstructive surgery (including drug provision in the treatment of a disease that caused disability), technical means of medical rehabilitation, including prosthetics and orthotics , a conclusion on sanatorium treatment with a prescription for the profile, frequency, duration and season of recommended treatment, on the need for special medical care for persons affected by accidents at work and occupational diseases, on the need for medicines to treat the consequences of accidents with radiation at work and occupational diseases, other types of medical rehabilitation) Chairman of the medical commission: ___________ ____________________ (signature) (signature) Members of the medical commission: ____________ __________________________ (signature) (signature) ____________ __________________________ (signature) (signature) ____________ ____________________ ( signature) (signature transcript) M. P. __________________________________________________________________ Cut line To be returned to the organization,

(approved by order of the Ministry of Health of Russia dated May 14, 1997 No. 141)

Form No. 088 / y-97 is filled out for persons sent for the first time to the ITU (including face-to-face consultations) and for disabled people sent for re-examination.

The procedure for filling out the “Referral to ITU” is determined by the Instruction introduced by order of the Ministry of Health of the Russian Federation of December 15, 1999 No. 06-23 / 6-2.

In the line "Date of issue" - indicates the date of issue of the referral to the person sent to the ITU or his legal representative.

In line 1 - the “full name” of the person being sent is indicated in full.

In line 2 - "Date of birth" - day, month and year of birth; "sex" - "m" or "f".

In line 3 - "Address of the patient" - the place of residence according to the passport.

Line 4 - "Disabled ___ group" - indicates the group of disability based on the available ITU certificate, or a dash if the patient is sent for the first time.

Line 5 - "Place of work" - indicates the name of the organization in which the sent person works at the time of filling out the referral. If a citizen does not work, an appropriate entry is made about this.

Line 6 - “Address of the place of work” - indicates the address of the organization in which the person sent on the day of opening the sick leave is working.

Line 7 - "Profession" - indicates the profession that was obtained through special education (engineer, teacher, construction technician) or the one in which there is the longest work experience and (or) the highest qualification.

Line 8 - "Position" - indicates the position in which the patient was occupied on the day the l / n was opened for him

Line 9 - “Under the supervision of a medical institution with ...” indicates the date of the initial filling out of the outpatient card of the patient in the health facility.

In line 10 - "History of the present disease" - during the initial registration of the referral to the ITU, details are given about the onset of the disease (the nature of the injury, injury), the course, the date of exacerbations (indicate the frequency and duration of exacerbations for the 12 months preceding the referral of the patient to the ITU, information about the nature of the treatment performed (outpatient or inpatient, indicating the profile of the department), types of treatment (therapeutic, surgical, physiotherapy, etc.) When making a referral for re-examination, line 10 indicates information about the course of the disease for the period elapsed from the date of establishment disability groups.

Line 11 - “Results of the rehabilitation measures taken” - indicates information about the measures to restore the patient's ability to work and their effectiveness, or measures to implement an individual program for the medical rehabilitation of a disabled person when he is sent for re-examination.

Line 12 - “Frequency and duration of temporary disability over the past 12 months” in the column “Numbers from ____ to ____” indicates the dates of opening and closing l / n, the total number of days of VN is indicated in the last line or under the line. If the patient does not work, then this section indicates the frequency of requests for medical care in health facilities and the name of the diseases for which the patient applied. In the column "Name of the disease" - on the line corresponding to the date of issue of the l / n, the name of the disease is indicated, for which the patient was recognized as temporarily disabled in the corresponding period.

In line 13 - “Name of the profession and working conditions for the last year” - indicates the profession (position) that the patient was performing at the time of issuing a l / n to him, as well as the predominant production factor, the severity of physical and neuro-emotional stress, etc. . Information is recorded from the words of the patient, if necessary, requested from the place of work.

In line 14 - "The condition of the patient when referring to the ITU" - when describing the objective status, each specialist describes in detail and consistently the patient's complaints, primarily related to the underlying disease (determining permanent disability), then others; the data of an objective examination of the patient by specialists are reflected with exhaustive completeness (conclusions of a therapist, neurologist, surgeon, oculist, and for women - a gynecologist are required).

In lines 15 - "X-ray studies", 16 - "Laboratory studies", 17 - "Additional research methods" - the results of studies confirming the established diagnosis of the underlying disease, and others that, to one degree or another, may influence the course of the underlying disease, are entered .

In line 18 "Diagnosis when referring to the ITU":

In paragraph 1 - "the main disease" - a detailed diagnosis is indicated in accordance with ICD-10, etiology, course features, stage, degree of functional impairment. When several diseases are combined, the disease that determines disability is indicated as the main one.

Clause 2 - “comorbidities” - indicates those diseases that are not decisive in the assessment of disability;

Clause 3 - "complications" - indicates the complications of the underlying disease.

In line 18.1 - "Violations of the basic functions of the body" (according to the adopted Classification of 01.29.97 No. 1/30), the patient's violations are indicated in accordance with section 1.2 "Classification of violations of the main functions of the human body."

In line 18.2 - "Signs of disability" (according to the adopted Classification dated 01/29/97 No. 1/30) the patient's OB is indicated in accordance with section 1.5 "Classification of vital functions disorders".

In line 19 - “The basis for referral to the ITU: the presence of signs of disability; the end of the period of disability; early re-examination; the need to extend the l / n (underline) ”- the necessary is underlined. If it is necessary to extend the l / n, it is extended within the period established by clause 2.3. instructions "On the procedure for issuing documents certifying temporary disability".

Responsibility for the correct execution of the "Referral to ITU" lies with the chairman of the KEK. The direction to the ITU is signed by the members of the KEK, the date is indicated, the seal of the medical facility is affixed. The decision of the CEC to send the patient to the ITU is recorded in the card of the outpatient (inpatient) patient and in the account. No. 035 / y - 02 "Journal of accounting for clinical and expert work of health care facilities."

More on the topic The order of filling f. No. 088 / y-97 "Referral for medical and social examination":

1. The procedure for filling f. No. 088 / y-97 "Referral for medical and social examination"

The line "Date of issue" indicates the date of issue of the "Referral for medical and social examination by an organization providing medical and preventive care" to a citizen sent for a medical and social examination or his legal representative.

In line 1, the last name, first name, patronymic of the citizen sent for medical and social examination are indicated in full.

Line 2 “Date of birth” indicates the day, month and year of birth.

In line 3, the gender of the citizen is indicated in abbreviated form: “m” or “f”.

Line 4 “Surname, name, patronymic of the legal representative of a citizen” is filled in in full if there is a legal representative.

In line 5 “Address of the place of residence of a citizen”, in the absence of a place of residence, the address of stay, actual residence on the territory of the Russian Federation is indicated.

In line 6 “Not a disabled person, a disabled person of the first, second group, category “disabled child” of the group”, the disability group is indicated on the basis of the certificate of the medical and social examination institution that the disabled person has about the established disability group or it is emphasized “not a disabled person” if the patient sent for the first time.

Line 7 “The degree of limitation of the ability to work” is filled in upon re-sending on the basis of the certificate of the institution of medical and social examination that the citizen has about the established disability group and the degree of limitation of the ability to work, the degree is indicated (first, second, third, not established).

Line 8 “Degree of loss of professional ability to work as a percentage” is filled in during a re-examination on the basis of a certificate of a medical and social examination institution that a citizen has on determining the degree of loss of professional ability to work.

Line 9 emphasizes whether a citizen is first or re-sent to the ITU.

Line 10 “Who works at the time of referral for medical and social examination” should indicate the position, profession, specialty, qualifications and length of service in the specified position, profession, specialty, qualifications; in relation to non-working citizens, make an entry: “does not work”.

Line 11 “Name and address of the organization in which the citizen works” indicates the name of the organization with the address in which the person being sent works on the day the sick leave is opened. If a citizen does not work, an appropriate entry is made about this.

In line 12 “Conditions and nature of the work performed”, information is recorded from the words of the patient, if necessary, requested from the place of work in the form of production characteristics (duration of the working day, shift; manual labor, machine-manual, mental, conveyor: position at work (in percent: sitting, standing, variable, walking); degree of physical stress: permanent (mild, moderate, severe) and temporarily (mild, moderate, severe); degree of neuropsychic stress: permanent (mild, moderate, severe) and temporary ( light, moderate, heavy); administrative work (large, medium, small volume), indicate the number of subordinates; the presence of unfavorable working conditions (work in a hot shop, in the cold, increased dust and gas pollution, exposure to chemicals, at height, with vibration).

Line 13 “Main profession (specialty)” indicates the profession obtained through special education (for example, engineer, teacher, construction technician), or the profession in which there is the longest work experience and (or) the highest qualification (for example, a repairman V category, etc.).

Line 14 “Qualification in the main profession (class, rank, category, rank)” should indicate the qualification that the patient had on the day the sick leave was opened.

Lines 15, 16. 17 are filled in for citizens who are studying at an educational institution at the time of being sent for a medical and social examination (full-time or part-time department). Line 15 indicates the name and address of the educational institution, line 16 indicates the indicated group, class, course, line 17 indicates the profession (specialty) that a citizen sent for a medical and social examination will receive upon graduation from an educational institution.

Line 18 “Observed in organizations providing medical and preventive care since _____” indicates the date of initial filling out of the patient's outpatient card in a medical institution.

In line 19, during the initial registration of a referral for a medical and social examination, details are given about the onset of the disease (the nature of the injury, injury), the course, exacerbations (indicate the frequency and duration of exacerbations in the 12 months preceding the patient's referral for a medical and social examination), information on the nature of the treatment performed (outpatient or inpatient with an indication of the department’s profile), types of treatment: therapeutic, surgical, physiotherapeutic, etc. When making a referral for re-examination, information is indicated on the course of the disease for the period that has elapsed since the date of establishment of the disability group, the identified in this period of new cases of diseases that led to persistent violations of body functions.

Line 20 “Anamnesis of life” is filled in at the primary referral. The diseases transferred in the past, injuries, poisonings, operations, diseases for which heredity is burdened are listed. In relation to the child, it is additionally indicated how the mother's pregnancy and childbirth proceeded, the timing of the formation of psychomotor skills, self-service, cognitive-playing activities, skills of neatness and self-care, how the development proceeded (by age, lagging behind, ahead of schedule).

In line 21 “Frequency and duration of temporary disability for the last 12 months” in the columns “Date (day, month, year) of the beginning of temporary disability” and “Date (day, month, year) of the end of temporary disability” indicate the dates of opening and closing of disability sheets , in the column “number of days (months and days) of temporary disability” the total number of days of temporary disability is indicated. If the patient does not work, then this section indicates the frequency of his requests for medical care to a medical institution and the diagnosis of diseases for which the patient applied to a medical facility. The column "Diagnosis" indicates the diagnosis of the disease, for which the patient in the relevant period was recognized as temporarily disabled or sought medical help.

Line 22 “The results of the measures taken for medical rehabilitation in accordance with the individual rehabilitation program for a disabled person” indicates information about measures to restore the patient’s ability to work, specific types of restorative therapy, reconstructive surgery, spa treatment, technical means of rehabilitation, including prosthetics and orthotics, as well as the terms in which they were provided; lists the functions of the body that could be compensated or restored in whole or in part, or a note is made that there are no positive results.

In line 23 “State of a citizen when referring to a medical and social examination (complaints, data of examination by the attending physician and doctors of other specialties are indicated), when describing the objective status, each specialist describes in detail and consistently the patient’s complaints, first of all related to the underlying disease, then others, with exhaustive completeness, the data of an objective examination of the patient by specialists are reflected, while the specialty of the doctor (therapist, surgeon, neurologist, etc.) is indicated.

In necessary cases, for records of the patient's condition, the results of the examination, specialists can use an insert for the referral of an arbitrary form, which must be sealed and signed by the chairman of the medical commission and members of the commission.

Line 24 indicates the results of laboratory, radiological, endoscopic, ultrasound, psychological, functional and other types of studies.

Line 25 indicates the body weight of a citizen in kg, height in meters, body mass index. The latter is calculated by the formula:

BMI = Weight (kg) / Height (in meters) squared

Preobesity 25–29.9

Obesity I degree 30–34.9

Obesity II degree 35–39.9

Obesity III degree 40 or more

A person's height is measured using a stadiometer. Normally, the height of men ranges from 160-180 cm, women 155-170 cm. Body weight is determined using medical scales.

Line 26 gives an assessment of physical development - normal, deviation (lack of body weight, excess body weight, short stature, high stature) - the necessary one is underlined. Physical development is a set of morphological functional features of the body that determine the reserve of its physical strength, endurance and performance.

In line 27 “Assessment of psychophysiological endurance: norm, deviation”, the necessary one is underlined. Psychophysiological endurance is the ability of a person to maintain any activity for a long time without reducing the effectiveness of its implementation, i.e. in a broad sense - performance. Psychophysiological endurance is determined by the degree of physical development, the state of the functional systems of the body, personality traits, temperament, the level of motivation to perform activities, and other factors. Psychophysiological stability is assessed by a psychologist based on an analysis of the dynamics of psychophysiological and physiological indicators in the process of performing psychological tests, sensory, sensorimotor and physical loads, as well as knowledge that simulates various types of household, professional and other activities. At the same time, it is not just the level of development or the state of certain functions that is assessed, but, first of all, their characteristics such as stability and the ability to maintain activity at a certain level for a long time.

In line 28 “Assessment of emotional stability: norm, deviation”, the necessary one is underlined. Emotional stability is a trait that expresses the preservation of organized behavior in normal and stressful situations and is characterized by maturity, excellent adaptation, the absence of great tension, anxiety, a tendency to leadership, sociability; emotional instability - extreme nervousness, instability, poor adaptation, a tendency to quickly change moods, feelings of guilt and anxiety, anxiety, depressive reactions, absent-mindedness, instability in stressful situations, impulsiveness, unevenness in relationships with people, variability of interests, self-doubt, pronounced sensitivity, impressionability, propensity to irritants. Emotional stability is assessed by a psychologist using various projective techniques, questionnaires and scales.

In line 29 "Diagnosis when referring to a medical and social examination" in paragraph “a”, the code of the underlying disease according to ICD-10 is indicated; in paragraph “b” a detailed diagnosis is indicated, reflecting the nosological form of the disease in accordance with ICD-10, etiology, course features, stage, degree of functional disorders. When several diseases are combined, the main disease is indicated, which determines the presence of signs of disability; in paragraph “c” “comorbidities” indicate those diseases that are not decisive in the assessment of disability; in paragraph “c” the complications caused by the underlying disease are indicated.

Line 30 “Clinical prognosis: favorable, relatively favorable, doubtful (uncertain), unfavorable” is underlined. Clinical prognosis - a medical assessment of the outcome of the disease, taking into account the nature of the disease and its course, stage, severity of symptoms, the degree of dysfunction of the affected organs and systems and the state of their compensation, as well as the effectiveness of adequate treatment. The prognosis can be: favorable - complete recovery or compensation of functions impaired as a result of illness, injury or injury, leading to disability; relatively favorable - incomplete recovery with residual manifestations, reduction, stabilization or partial compensation of impaired functions leading to disability, in case of a chronic disease - slowing down the progression of the disease, prolongation of remission periods, etc., doubtful - unclear course of the disease, unfavorable - impossibility of stabilization state of health, stopping the progression of the pathological process and reducing the degree of violation of the functions of the body, leading to limitation of life. In order to predict the degree of recovery of impaired functions, it is possible to use various tests and scales.

In line 31 “Rehabilitation potential: high, satisfactory, low”, the necessary is underlined. Rehabilitation potential is a set of preserved physical, psychophysiological, mental abilities and inclinations that allow a person to compensate or eliminate, to one degree or another, the limitations of life activity that have formed as a result of an illness or defect. High rehabilitation potential - full restoration of health, all types of life that are usual for a person, working capacity and social status. Satisfactory potential - incomplete recovery with the preservation of a moderately pronounced dysfunction, the performance of the main activities with limited labor or with the help of technical aids. Low rehabilitation potential - progressive course of the disease, severe dysfunction; a significant limitation in the performance of most activities, expressed by a decrease in working capacity and the ability to social integration; the need for social support and constant material assistance. The rehabilitation potential is assessed by the attending physician, who directs the citizen to a medical and social examination.

In line 32 “Rehabilitation prognosis: favorable, relatively favorable, doubtful (uncertain), unfavorable” the necessary is underlined. Rehabilitation prognosis - the estimated probability of realizing the rehabilitation potential and the estimated level of integration of the disabled person into society. The rehabilitation forecast is determined not only by the level and content of the rehabilitation potential, but also by the real possibilities of using modern rehabilitation technologies, means and methods for its implementation. The rehabilitation prognosis is assessed as: favorable - with the possibility of complete restoration of impaired body functions and categories of disability, full social, including professional integration of a disabled person; relatively favorable - the possibility of partial restoration of impaired body functions and categories of disability, with a decrease in the degree of their limitations or stabilization, with an expansion of the ability to integrate and move from full to partial social support; doubtful (uncertain) - unclear forecast; unfavorable - the impossibility of restoring or compensating for impaired body functions and categories of life restrictions. The rehabilitation prognosis is assessed by the attending physician, who directs the citizen to a medical and social examination.

Line 33 indicates the purpose of the referral for a medical and social examination (the necessary is underlined): to establish disability, the degree of limitation of the ability to work, the degree of loss of professional ability as a percentage, to develop (correct) an individual rehabilitation program for a disabled person (a program for the rehabilitation of a victim as a result of an accident accident at work and occupational disease), for another (specify).

Line 34 “Recommended measures for medical rehabilitation for the formation or correction of an individual program for the rehabilitation of a disabled person, a program for the rehabilitation of a victim of an accident at work and an occupational disease” indicates specific types of rehabilitation therapy (including drug provision in the treatment of a disease that caused disability), reconstructive surgery, technical means of medical rehabilitation, including prosthetics and orthotics, a conclusion on sanatorium treatment with a prescription for the profile, frequency, duration and season of recommended treatment, on the need for special medical care for persons injured as a result of accidents at work and occupational diseases, the need for medicines for the treatment of the consequences of accidents at work and occupational diseases, other types of medical rehabilitation.

The direction is signed by the chairman of the medical commission, members of the commission with a transcript of the signatures and sealed with the seal of the medical institution.

Responsibility for the correctness of filling out Form No. 088 / y-06 “Submission for medical and social examination by an organization providing medical and preventive care” rests with the chairman of the medical commission of the medical institution, or with the head physician.

The form must be submitted to the Bureau of Medical and Social Expertise no later than 1 month from the date of its issuance.