Statistical Card of the patient discharged from hospital,

Health´s Ministry of Russian Federation___________________ name of medical establishment

Medical documentation Form N 066/r-02 Approved by order of Health´s Ministry of RF from 30.12.2002. N 413

Statistical Card of the patient discharged from hospital,

daily establishment in the hospital,

daily establishment in the polyclinic, hospital at home

N of medical card ___________

1. Patient´s code: <*> ____________________________ 2. Name: _________________________

3. Sex: M - 1; F - 2 4. Date of birth _ _._ _._ _ _ _

5. Document identity person: passport, series, №_______________________________

6. Address : place of registration____________________________________________

7. Registration place´s code: ___ Place of living: city - 1; village - 2.

8. Insurance policy (series, №): ___________________________________________________

Issued: by whom __________________________________________ Code of territory: _ _ _

9. Kind of payment: OMI - 1; budget - 2; paid services- 3; DMI- 4; other - 5.

10. Social status: preschool child- 1: organized - 2; not organized - 3;

pupil - 4; employment - 5; not employment - 6; homeless - 7; pensioner- 8;

soldier- 9; Code _ _ _; family member of soldier - 10.

11.Category of benefit: invalid of GPW- 1; participant of GPW- 2; soldier-internationalist - 3; a person exposed to radiation - 4; including in Chernobyl- 5;

inv. I gr. - 6; inv. II . gr - 7; inv. III gr. - 8; disabled child- 9;

disabled since childhood - 10; others - 11.

12. Who directed the patient_______ N of form ___________________ Date: _ _._ _._ _ _ _

13. who delivered the patient___________________ Code _ _ № of array _________________

14. The diagnosis of department which directed ______________________________________

______________________________________________________________________________________

15. The diagnosis of department which delivered________________________________________

______________________________________________________________________________________

16. Delivered intoxicated: <**> Alcoholic - 1; Narcotic - 2.

17. Hospitalized due particular disease for the first time during the given year - 1; twice - 2; in emergency- 3; planned - 4.

18. Duration of hospitalization: at first 6 hours - 1; 7-24 hours - 2; more than 24 hours - 3.

19. Trauma: - industrial: manufacturing - 1; transport - 2, including accident- 3;

agriculture- 4; others - 5;

- non-industrial: domestic - 6; street - 7; in road transport - 8,

Including accident - 9; school - 10; sport - 11;
unlawful - 12; others - 13.

20. Date of hospitalization: _ _._ _._ _ _ _ Time _ _. _ _

21. Name of department ____________________ Date of admission __________ Time _______.

Doctor´s signature ______________________ Code _ _

22. Date of discharge(death):_ _._ _._ _ _ _ Time _ _._ _

23. How long the patient was admitted(bed days): _ _ _

24. Result of hospitalization: discharge - 1; including to the daily establishment - 2; to the all-day establishment - 3; transferred to another medical establishment - 4;

24.1. Result of treatment: recovery - 1; improved - 2; without any change - 3;

worsening - 4; healthy - 5; died - 6.

25. Work disability form: open _ _._ _._ _ _ _ close:_ _._ _._ _ _ _

25.1.To care for the sick Full years: _ _ Sex: M. 1 F. 2

--------------------------------

<*> identification code of patient or other, which was adopted in the department

<**> The definition of drunkenness in accordance with the procedure established by the Ministry of Health of Russia.

26. Movement of the patient in the departments:

N	Code of department	Kind ( profile) of beds	Doctor´s code	Date of hospitalization	Date of discharge or transfer <***>	code of ICD-10	Code of medical standard <*>	Code of interrupted case <**>	Kind of payment
	2	3	4	5	6	7	8	9	10
1.
2.
3.
4.
5.
6.

--------------------------------

<*> Flexible if approved in the Russian Federation in the established order.

<**> To be completed using a payment system.

<***> At discharge, a transfer from intensive care unit to specify the residence time in hours.

27. Surgical operations(mark: basic operation, the use of special

equipment):

Date, time

Surgeon´s code

Code of department

Operation

Complication

Anesthesia
<*>

the use of special equipment

Kind of payment

Name

code

Name

code

endoscopy

lazer

cryogenic

--------------------------------

<*>Anesthesia: general - 1, local - 2.

┌───┐ ┌───┐

28. Investigations: RW 1 └───┘ AIDS 2 └───┘

29. Diagnosis of hospital( at discharge):

Clinical final diagnosis	Main diagnosis	code of ICD-10	Complication	code of ICD-10	Accompanying disease	code of ICD-10
Clinical final diagnosis
Pathological Anatomy

30. The mail cause of the death_________________________________________

________________________________________________________ code of ICD-10 __________________

31 Defects in pre-hospital phase: untimely hospitalization - 1; inadequate volume of clinical - diagnostic examination- 2; inadequate treatment strategy - 3;

Divergence of diagnosis - 4.

Doctor´s signature _______________________

^{Signature of chief of department} ______________________