Ikhadi lezokwelapha lomuntu ogulayo: ifomu. Ukubhaliswa kwekhadi lezempilo lesiguli

Inombolo yemibhalo ehlukene yezokwelapha esetshenziswa odokotela okwamanje inkulu kakhulu. Ngesikhathi esifanayo, enye yezindawo eziphakathi ihlala ekhadini lezokwelapha lomguli omileyo. Le dokhumenti inesakhiwo esimisiwe, noma kunjalo, kuye ngokuthi isikhungo esithile sibheke kanjani, singase sihluke emininingwaneni engadingekile.

Iziphi izingxenye ezisemkhokheni wezokwelapha?

Ehlangothini layo langaphambili kunendawo yokukhombisa igama lokugcina lesiguli, igama lokuqala negama lomlando, igama lesigceme nenombolo yesigceme, ukuxilongwa kokugcina, nezinsuku zokungeniswa nokukhishwa.

Ikhasi langaphambili lilandela ingxenye yokuphatha. Zonke izidingo ezidingekayo zesiguli zikhonjisiwe lapho. Sikhuluma ngesibongo sakhe, igama kanye ne-patronymic, indawo yokubhalisa, inombolo yepasipoti, uhlobo lwezokwelapha (isabelomali noma ikhokhwe), inhlangano eyathumela isiguli esibhedlela.

Ukuxilongwa

Ngemuva kolwazi jikelele mayelana nesiguli, ishadi lezokwelapha lesiguli esinezifo ezigulayo liyaqhubeka neshidi lapho kutholakala khona ukuxilongwa. Ngemuva kokuba isiguli singena emnyangweni wokufaka izicelo, kulesi sigaba ukuthi ukuxilongwa kwenhlangano yokuthumela kubonisiwe. Kumele kuqashelwe ukuthi akulona iqiniso ngaso sonke isikhathi. Khona-ke kukhona indawo yokuxilongwa komtholampilo. Le ngxenye igcwaliswa udokotela ovela emnyangweni wephrofayela lapho isiguli siphathwa khona. Lesi sigaba kufanele sikhishwe zingakapheli izinsuku ezintathu (lesi yisikhathi esinikezwe udokotela ukucacisa imbangela yesifo). Ngemuva kwalo kunesimo esikhethekile, esibonisa ukutholakala kokugcina, okungukuthi, okushiwo isiguli. Kungenzeka kube nokungafani okuvela emtholampilo. Lapha, hhayi kuphela igama le-pathology ngokwalo elifakiwe, kodwa futhi ikhodi yalo, enqunywe ngokwesigaba se-ICD-10.

Ukuqapha okunamandla

Lokhu akuqedi ishadi lezokwelapha lomuntu ogulayo. Isampula kwanoma imuphi umlando wezokwelapha uhlanganisa ulwazi mayelana nesimo sesiguli. Kulokhu, kunezigaba ezimbili ezinikezwe ngokukhethekile. Ishadi lezokwelashwa lesiguli esibhedlela singenendawo yedatha yokuhlolwa okuningiliziwe nguDokotela wophiko lokumamukela. Owesibini kubo "Ukuhlolwa okuyinhloko ngudokotela oya khona". Ngesikhathi esifanayo, lokhu kungenziwa ngokuzimela, kanye nenhloko yomnyango noma kanye nodokotela bephrofayela ehlukile.

Ngaphezu kwalokho, ishadi lezokwelapha lesiguli esineziguli lihlanganisa nesigaba esidingekayo ukuze unike amandla udokotela ukwenza ulwazi lomlando ngezivivinyo ngezikhathi ezithile zesiguli. Le ngxenye yenzelwe udokotela ukuba akwazi ukugcina inkambo yekliniki yalokhu noma leyo pathology. Ngenxa yalolu grafu, ukuqhubeka phakathi kwabasebenzi bezokwelapha kwenziwa lula. Ngokwesibonelo, kwenzeka ukuthi isiguli siholwa udokotela oyedwa kuqala, bese esaya kwesinye isazi. Ngaphandle kolwazi olubonisa lokho okwenzekayo ngesiguli ngaphambili, udokotela omusha uzobe ephazamiseka ngokushesha ekuqondiseni uhlelo lwezokwelapha.

Ukwengeza, ifomu lesikhathi sezokwelashwa sesiguli esinezifo ezibandakanya isigaba esidingekayo sokungena kwamarekhodi ngababonisi bezokwelapha.

Isigaba sokuthola

Ihlanganisa ishadi lezokwelapha zesiguli esibhedlela. Ifomu ngezingcwaningo ezitholiwe, kanye nemiphumela yokucwaninga ngezixhobo kuzokusiza udokotela ngokushesha ukuthi akwazi ukuqondisa futhi athole ukuxilongwa kweqiniso kuphela.

Kula makhasi, udokotela angakwazi ukuqhathanisa zonke izinkomba ezidingekayo ngenxa yesifo esithile sokusola. Ngokuhamba kwesikhathi lesi sigaba singafakwa ngemiphumela yezifundo ezintsha.

I-Epicrisis

Ukubhaliswa kwekhadi lezokwelapha lomguli omileyo kuqhubeka nokubhala kwe-epicrisis. Lesi sigaba luhlobo oluthile lwengcaphuno emfushane kusuka kuzo zonke ezinye izingxenye zomlando wezokwelapha. Lapha udokotela ubonisa lonke ulwazi olubaluleke kakhulu ngesimo sokuqala kwesiguli, ukuxilongwa okuqinisekisiwe, imiphumela yokuhlolwa kwelabhoratri kanye nezifundo zezinsimbi, kanye nomthamo nokusebenza kokwelashwa. Ngokuvamile ku-epicrisis, ukugcwaliswa kwirekhodi yezokwelapha lomguli omileyo kuphela.

Khipha

Ngemuva kokuthi umuntu asebenze ngokugcwele esibhedlela, ukhululiwe emnyangweni. Ngesikhathi esifanayo, idokhumenti eqinisekisa ukuthi uhlala esibhedlela inikezwe isiguli esivele isesiguli. Ngezindlela eziningi kufana ne-epicrisis. Lokhu kukhishwa kuyadingeka kumuntu ngesizathu sokuthi uqinisekisa ukuthi udokotela usungule lokhu noma ukuthi ukuxilongwa. Kumele kuthathwe ku- polyclinic endaweni yokuhlala. Lokhu kuyadingeka ukuqinisekisa ukuthi udokotela ophatha umuntu ngesineke unolwazi olugcwele mayelana ne-pathology ekhona esigulini sakhe. Ngaphezu kwalokho, izitshalo zokuqala ezivela esibhedlela zingadingeka uma kwenzeka umuntu adinga ukubhalisa iqembu lokukhubazeka nge-MEDN.

Ekugcineni, isiguli ngokwakhe sidinga ukukhipha. Iqiniso liwukuthi izigaba zalo zokugcina ziyi "Izincomo". Lapho, udokotela ubonisa konke okudingeka ukuthi isiguli sikwenze ukuze kuqinisekiswe ukuthi inqubo yokutakula iya ngokushesha futhi ingabuyeli. Ukuhambisana nezincomo kuyisimo esibaluleke kakhulu sokuvimbela ukuqhubeka kwesifo esingenasifo esivele sikhona, kanye nokunciphisa amathuba okuba nokugula okunamandla.

Iyini umlando wesifo?

Okokuqala, kuyidokhumenti yomthetho engaba yinye yamadokhumenti ayisihluthulelo ekuxazululeni izingxabano ezithile. Uma isiguli sinesikhalazo ngodokotela wakhe noma, ngokuphambene nalokho, abasebenzi bezokwelapha banezikhalo ngomuntu othola ukwelashwa okwelashwa esikhungweni sabo, ngakho konke ukunakekelwa kuphinde kudonsele emlandweni wezokwelapha.

Olunye umsebenzi obalulekile kunoma yiliphi ishadi lezokwelapha lomguli omileyo ukukhulumisana phakathi kwabadokotela bezikhungo ezahlukene. Udaba ukuthi ukukhishwa kwenziwa ngesisekelo somlando wezokwelapha. Kukhona kokubili okusungulwe esibhedlela, futhi yonke imiphumela yezifundo ze-laboratory nezinsimbi ezenziwa esibhedlela. Uma kwenzeka umuntu ekhishwa emtholampilo, udokotela wakhe uyoba nolwazi oluphelele ngaye.

Njengamanje, izindlela ezintsha zokudluliselwa kokukhishwa kwesibhedlela kunethiwekhi yezokwelapha zithuthukiswa ukukhulisa ukuxhumana phakathi kwezikhungo zezempilo. Okokuqala, sikhuluma mayelana nobuchwepheshe bekhompyutha, okuvumela ukuba udlulisele ulwazi oluningi nge-Inthanethi. Le ndlela ilula kakhulu, kodwa idinga ukuthuthukiswa kwesofthiwe engathí sina ukwenza lula ukuthola i-polyclinic lapho umuntu anikezwa khona, kanye nokuvikelwa okugcwele kwedatha edlulisiwe kusuka ekufinyeleleni okungagunyaziwe ngabanye abantu.