Work plan for a local therapist. Organization of the work of a local therapist. Structure of the clinic's work

18.10.2019 -

Appendix No. 1. Regulations on the organization of activities of a local physician Appendix No. 2. Registration form N 030/u-ter "Passport of a medical district (therapeutic)"

Order of the Ministry of Health and social development RF
dated December 7, 2005 N 765
"On the organization of activities of a local physician-therapist"

In accordance with subclause 5.2.11. paragraph 5 of the Regulations on the Ministry of Health and Social Development Russian Federation, approved by Decree of the Government of the Russian Federation of June 30, 2004 N 321 (Collection of Legislation of the Russian Federation, 2004, N 28, Art. 2898; 2005, N 2, Art. 162), and in order to further improve the organization of primary health care to the population, I order :

2. Development Department medical care and resort business (R.A. Khalfin) to develop instructions for filling out registration form N 030/u-ter “Passport of a medical area (therapeutic)” by April 1, 2006.

3. Department of Labor Relations and State civil service(Safonov A.L.) and the Department pharmaceutical activities, ensuring human well-being, science, education (N.N. Volodin) to develop qualification requirements for a local general practitioner by June 1, 2006.

4. The Department of Pharmaceutical Activities, Human Well-Being, Science, Education (N.N. Volodin) to review the retraining and advanced training programs for local general practitioners by June 1, 2006.

5. Entrust control over the implementation of this order to Deputy Minister V.I. Starodubova.

M.Yu. Zurabov

The Regulations on the organization of activities of a district physician were approved. According to the Regulations, specialists with a higher education degree are appointed to the position of local physician-therapist. medical education in the specialty "General Medicine" or "Pediatrics" and a specialist certificate in the specialty "Therapy".

It has been established that the local general practitioner carries out activities to provide primary health care to the population in medical organizations primarily in the municipal health care system: clinics; outpatient clinics; in-patient clinics of the municipal health care system; other medical and preventive institutions providing primary health care to the population.

The regulation assigns responsibilities to the local general practitioner for: forming a medical (therapeutic) area from the population attached to it; implementation preventive measures to prevent and reduce morbidity; organizing and conducting diagnostics and treatment; providing emergency medical care; carrying out anti-epidemic measures and immunoprophylaxis; conducting an examination of temporary disability and many others.

In the domestic healthcare system, as already mentioned, there is outpatient care to the population(from lat. ambulatory- mobile). Outpatient clinics are designed to provide assistance to incoming patients, as well as patients at home.

Brief historical outline of the development of outpatient care in Russia

For the first time, outpatient care for patients in Russia began to be used in the 11th century. In 1089 Kievan Rus“free healing” for visiting patients was made the responsibility of “hospitals located at churches.” Outpatient “reception” of patients was also carried out by healers and healers, to whom ordinary people turned for help. Until the 16th century. medical affairs were not subject to the jurisdiction of the state, since Rus' was fragmented into feudal principalities, on the territory of which, although sanitary and quarantine measures were introduced (under the control of a prince or monastery), both Russian and foreign doctors were invited to serve, there was no single organization or health service was. And only after the creation of a centralized Russian state under the rule of Moscow became possible the organization of state medical institutions and publication of relevant regulations on medical matters. Thus, by decree of Ivan the Terrible, the so-called Tsareva, or Court, pharmacy was established (1581), which performed the functions of providing medical assistance to the tsar, his family, and fellow boyars. Soon a Pharmacy Order was established to manage the medical affairs of the state.

In 1620, the first secular outpatient clinics appeared, where doctors treated patients. The organization of outpatient care was accelerated by severe epidemics of smallpox, plague, and cholera.

Peter's reforms gave rise to the reorganization of the entire medical business: instead of the boyar order system, a state administration was created, including the Medical Office instead of the Pharmacy Order. In 1738, the position of a doctor for the poor was established at the main pharmacy of St. Petersburg; this was the first free outpatient clinic in Europe.

In 1804, for the first time in the history of Russia, outpatient practice was introduced into the teaching program at medical faculties of universities. As a rule, outpatient care in cities was provided at hospitals. Independent institutions of this type began to develop only in the 80s. XIX century, which was facilitated by the development of zemstvo and factory medicine.

The zemstvo reform created a system of medical care, including local service, traveling medical assistance, provision of paramedics.

Outpatient care has received intensive development in our country since the 20s. XX century, i.e. during the formation years of the domestic healthcare system. Thus, by agreement of the People's Commissariat of Health of the RSFSR and the All-Russian Central Council of Trade Unions, medical aid stations, outpatient clinics, and hospitals began to be created at enterprises. In 1929, the Decree of the Central Committee of the All-Union Communist Party of Bolsheviks “On medical care for workers and peasants” was published, in which the main attention was paid to the organization of medical care, including outpatient care. Medical examination was declared an important method of prevention, which at that time, due to many objective reasons, was reduced to registration of diseases and medical examinations. The system of maternal and child health care has been improved, and the network of children's clinics and antenatal clinics has increased significantly. On the eve of the war, despite mistakes and miscalculations, repressions that claimed thousands of lives of healthcare professionals, a state healthcare system was built, which assumed a preventive focus, planning, accessibility, etc. By 1950, even taking into account the enormous damage caused to the national economy of the country during the war (40,000 hospitals and clinics were destroyed), the number of medical institutions not only reached pre-war levels, but also increased. In those years, medical examinations began to be carried out rural population, preparations are underway for medical examination at the clinic. From 1961 to 1983, outpatient care focused on clinical examination.

Organization of work of clinics and outpatient clinics

Currently, outpatient care is provided in a wide network of outpatient clinics and clinics that are part of hospitals, in independent city clinics and rural medical outpatient clinics, dispensaries, specialized clinics, antenatal clinics, health centers, paramedic-midwife stations, etc. In these institutions, approximately 80% of all patients begin and complete treatment and only 20% of patients are subject to hospitalization.

Thus, outpatient care is the most in mass form treatment and preventive care for the population.

The types of out-of-hospital care institutions were approved in 1978 by the USSR Ministry of Health. The leading ones are clinics and outpatient clinics.

Clinic(from Greek polis- city and clinic- healing) is a multidisciplinary medical and preventive institution designed to provide medical, including specialized, care to patients, and, if necessary, to examine and treat patients at home.

The clinic sees doctors of various profiles (therapists, cardiologists, gastroenterologists, ophthalmologists, surgeons, etc.), and also has diagnostic rooms (X-ray, endoscopic, laboratory, physiotherapy room, etc.).

The basic principle of the clinic is territorial-precinct, when the local physician-therapist and nurse a plot with a certain number of inhabitants is assigned. The local doctor and nurse are responsible for carrying out all therapeutic and preventive measures in the territory of this site. The territorial-precinct principle is also observed in relation to doctors of “narrow” specialties when they make house calls (as prescribed by the local therapist).

Outpatient clinic - This is a medical and preventive institution, which, like a clinic, is intended to provide medical care to patients coming to the outpatient clinic and to patients at home.

The operating principle of an outpatient clinic is also local, but an outpatient clinic differs from a clinic in that it has a smaller volume of work and capabilities. In outpatient clinics, usually located in rural areas, admission is only available in a small number of specialties (no more than five): therapy, surgery, obstetrics and gynecology, pediatrics. The work of a nurse in an outpatient clinic resembles the work of a district nurse in a clinic, but only the outpatient nurse is more independent.

Main tasks of the clinic are:

provision of qualified specialized medical care to the population in clinics and at home;
organizing and conducting medical examinations of the population;
organization and implementation of preventive measures among the population in order to reduce morbidity, disability, and mortality;
examination of temporary disability;
organizing and carrying out work on sanitary and hygienic education of the population, propaganda healthy image life.

Polyclinics can be independent or combined with a hospital, general or specialized, for example dental, spa, etc.

Main structural units of the city clinic

IN composition of the clinic includes the following divisions:

registry;
prevention department;
medical departments;
diagnostic department (laboratory, x-ray room, ultrasound diagnostic room, etc.);
statistical office;
administrative divisions ( chief physician, Deputy Chief Physician for Work Capacity Examination).

Registry ensures registration of patients for appointments with doctors and registration of doctor's house calls, timely selection and delivery of documentation to doctors' offices, information to the population about the time of doctors' appointments and the rules for calling a doctor at home, preparation of sheets and certificates of temporary disability.

Prevention department includes a pre-medical control room, a women's examination room, etc. Patients from the registry who come to see a doctor for the first time are sent to the prevention department. In the pre-medical control room, patients are systematized, various certificates are issued, and preliminary examinations are carried out.

IN composition of medical departments includes local therapists and doctors of “narrow” specialties. Each department is headed by a department head. The head of the clinic is the chief physician of the clinic (the clinic is an independent medical and preventive institution) or the deputy chief physician of the clinic (when the clinic is combined with a hospital).

IN statistical office polyclinics process and record documentation, analyze the performance indicators of the structural divisions of the polyclinic.

Organization of the work of a local therapist in a city clinic

Local therapist plays a leading role in the public health system (in the future this will be a family doctor). The complex work of a local doctor combines medical and organizational activities (organization of prevention, treatment, medical examination, rehabilitation, sanitary education work). A local doctor is essentially a front-line healthcare organizer.

It is the activities of the local general practitioner and local nurse that are most closely related to the work of social protection authorities and are largely medical and social. The local doctor and local nurse have an important influence on solving the client’s medical and social problems in their professional activities social worker. It is the local doctor who, if necessary, should be contacted by a social work specialist in case of difficulties of a client’s medical and social nature.

The work of a local general practitioner is usually organized in such a way that every day he sees patients in the clinic (about 4 hours) and makes calls to patients at home (about 3 hours). The doctor not only carries out calls made by the patient himself or his relatives, but also, if necessary (without calling), visits the patient at home. These calls are called active calls. The local doctor should visit chronically ill patients, lonely elderly people, and the disabled at least once a month, regardless of whether the patient called the doctor or not. When performing a call, the doctor not only treats the patient, but also performs elements social work: finds out the social and living conditions of the patient, contacts, if necessary, with social protection authorities, the RCCS department, pharmacies, etc.

The nurse also takes a direct part in the reception of patients (prepares the documentation necessary for the reception, writes prescriptions for medicines as directed by the doctor, fills out referral forms for examination, measures blood pressure, body temperature, etc.) and carries out doctor’s orders at the site (does injections, puts mustard plasters, enemas, checks patients’ compliance with the prescribed regimen, etc.). If necessary, the activities of the doctor and nurse at the site can be organized as a hospital at home, when the doctor visits the patient at home every day, and the nurse carries out medical prescriptions at home.

Clinical examination

Clinical examination is the main means of prevention in the domestic healthcare system.

Clinical examination is an active, dynamic monitoring of the health status of certain populations (healthy and sick), registering population groups for the purpose of early detection diseases, periodic monitoring and complex treatment sick, improving the health of work and life, to prevent the development of the disease, restore ability to work and prolong the period of active life.

Clinical examination involves examination and treatment of patients without exacerbation of the disease.

Clinical examination (or clinical examination method) consists of several stages. At the registration stage, patients are identified (based on the results of medical examinations or by referral, with the former being preferable). At the next stage, the patient is examined, his state of health is assessed, and working and living conditions are studied. At the third stage, a plan for preventive and therapeutic measures, draw up documentation. Then the patient is actively and systematically monitored, individual preventive treatment, recreational activities at the execution stage. Sanitary educational work, the formation of a healthy lifestyle, state and public measures to combat health risk factors are carried out at final stage(preventive measures).

The work of a local therapist carried out according to a schedule approved by the head of the department or the head of the institution. Drawing up a work schedule for local therapists is an important organizational event. A rationally designed work schedule allows you to increase the availability of a local physician-therapist for the population of your area, in particular, to ensure high degree observance of locality in serving the population. The work schedule should include fixed hours for outpatient visits, home care, preventive and other work.

When drawing up a schedule it is necessary to take into account the monthly balance of working time, strive to establish a uniform load at outpatient appointments, and reduce the loss of working time while waiting for an appointment. The working day is functionally divided into outpatient appointments at the clinic (outpatient clinic) and providing care to patients at home. The work time of a local therapist should not be automatically distributed equally between appointments at the clinic and work at the site, much less evenly throughout the week. It should be determined depending on the size and composition of the population of the site, its distance from the clinic, the level of attendance and the number of calls by day, season, etc.

When drawing up a schedule, the nature of the visits should also be taken into account: are they made for medical or for preventive purposes. On average, a doctor should work on an outpatient basis from 2.5 to 3.5 hours, and on providing care at home - from 3 to 4 hours, but to ensure differentiated planning of doctors’ working hours by type of activity and duration of patients’ appointments by day of the week, the head department determines the types of activities that should be included in work schedules and the days of the week with more high level attendance. After this, work schedules are drawn up for the month, in which differentiated lengths of time for receiving patients are planned by day of the week.

Appendix No. 3 to work program disciplines
MINISTRY OF HEALTH OF THE RUSSIAN FEDERATION

Federal state budget educational institution

higher education

"NORTHERN STATE MEDICAL UNIVERSITY"

Ministry of Health of the Russian Federation

METHODOLOGICAL INSTRUCTIONS FOR STUDENTS

BY DISCIPLINE____Outpatient therapy ____

Structure and content methodological instructions for students

Topic 1: “Organization of the work of a local doctor and therapeutic service in a clinic, qualification characteristics of the specialty”; " Primary documentation of the site."

Introduction

In terms of its significance, content and scope, the outpatient service occupies a leading place in healthcare. According to statistics, about 80% of patients begin and complete treatment in a clinic. A modern clinic is a multidisciplinary, specialized treatment and preventive institution in which therapeutic care occupies a dominant position. Outpatient care for therapeutic patients is provided by city and district clinics, I am in the countryside - local hospitals and outpatient clinics.

In outpatient clinics it is provided primary health care(PHC). Primary health care is a term that appeared in our healthcare relatively recently. In 1978, the largest international conference, at which the concept of primary health care was developed and the corresponding declaration was adopted. According to that declaration (WHO, 1978), the term primary health care means zone of first contact between a person (family, community) and the health care system. In our country, this area is the outpatient clinic service.

In recent years, in connection with the social changes taking place in our country and the formation of new economic relations, significant organizational changes have been noted in the healthcare system. But in primary care There were practically no personnel or structural changes. As before, most of the local therapists are dispatchers in the worst sense of the word, referring up to 50% of patients who seek medical help to various specialists and “machines” for discharge sick leave(by comparison, in Western countries, the USA and Canada, only 10% of patients are referred to consultants). Availability of “narrow” specialists (therapeutic profile) on the staff of health care facilities: a local doctor with with a light heart sends a patient with banal gastritis for treatment to a gastroenterologist, constipation of alimentary origin - to a proctologist, with symptoms of neurocirculatory dystonia - to a cardiologist or neurologist. And we are not talking here about a consultative appointment, but about all further treatment; at the same time, the role of the specialist is significantly reduced, since he is forced to perform the functions of a local doctor. In addition, in most constituent entities of the Russian Federation, priority in the provision of medical care is still given to more expensive inpatient and specialized assistance. Total quantity full-time positions of medical specialists working in hospitals increased by 15.9%, the number of bed days is increasing (at the same time, the number of positions occupied by local therapists decreased in rural areas by 9.6%, in the city - by 12.4%. Negative The results of the provision of medical care to the population are affected by a violation of continuity in patient management during the transition of patients from children's clinics to adults.

Thus, the existing system of organizing primary health care, focused on local and specialized services, is not effective enough. The functions of a local general practitioner, who must provide the bulk of primary medical care, currently do not allow for the provision of continuous and comprehensive care to various categories of patients, regardless of gender and age.

To eliminate the above negative points in the late 80s of the last century in Russia there was a mature understanding of the need to develop a system of doctors general practice. The task was set to train a specialist with a completely new profile, possessing wide range medical and social knowledge, taking into account the role of many factors in the occurrence pathological conditions organism responsible for the health of every member of society. In many countries around the world, such a doctor has become a general practitioner/family doctor (GP/GP). This is a trusted doctor who can be contacted by any family member, regardless of age, on issues of maintaining and promoting health. The GP/GP must provide continuous medical assistance to families at home, outpatient clinic, clinic, hospital. He must carry out diagnostic and treatment, preventive, rehabilitation, organizational and methodological work.
Purpose of the lesson: Assimilate general principles organization and provision of medical care to patients in the aspect of the activities of an outpatient therapist.
Tasks:

Study the main issues of organizing outpatient clinics therapeutic assistance, know the structure, functions of the clinic, organization of the work of the local therapist
Test and consolidate the basic theoretical knowledge and practical skills of a local doctor, acquired during self-training and during practical training as an assistant to a local doctor.
Get acquainted with and learn how to draw up the main primary documents used in the work of a local doctor
Become familiar with the main responsibilities of a primary care physician.
Get acquainted with the legislative documents regulating the activities of a local doctor.
Get acquainted with the concept of development of the healthcare system in the Russian Federation until 2020.

Qualification.

Primary documentation.

Performance indicators.

Regulatory documents.
Questions for the lesson

Functional responsibilities of a local doctor.
Continuity in the activities of a local doctor.
Temporary indicators of the work of a local doctor.
Qualitative indicators of the work of a local doctor.
Criteria for the effectiveness of the activities of a local therapist.
Registration and reporting forms of primary medical documentation used in the work of a local doctor.
Features of organizing home care.
Hospital-substituting forms of medical care in the clinic.
Basic legislative documents, used in the work of a local doctor.

Main documents:

Medical card outpatient (form 025/у);

Outpatient card (form No. 25-10/u-97);

Voucher for an appointment with a doctor (form 025-4/у);

Book of doctor's house calls (form 031/у);

Work diary of a doctor at a clinic (outpatient clinic), dispensary, consultation (form 039/u);

Control card dispensary observation(form 030/у);

Referral to consultation and auxiliary offices (form 028/у);

Extract from the medical record of an outpatient or inpatient patient (form 027/u);

Card of preventive fluorographic examinations (form 052/у);

Emergency Notice about an infectious disease, food, acute, occupational poisoning, unusual reaction to vaccination (form 058/у);

Referral to MSEC (form 088/u);

Certificate of incapacity for work; certificate of temporary disability of students, students of vocational schools, illnesses, quarantine of a child attending school, children's preschool(form 095/у);

Certificate for obtaining a voucher (form 070/у);

Sanatorium-resort card (form 072/у);

Recipe (form 107/у); a prescription for a medicine containing narcotic substances; prescription “free, payment 50%, 20% of cost”, etc. (form 108/u);
Self-control tasks:

City clinic: structure, tasks, functions. Organization and maintenance of the work of the therapeutic department of the clinic. Organization of medical care at home. Hospital-replacing technologies. Continuity in the provision of treatment and preventive care
Which order of the Ministry of Health outlines the organization procedure medical care population on a local basis.
What is the recommended size of the attached population at the therapeutic site.
Indicate the decreed contingents that are subject to mandatory dispensary observation by a local doctor.
List the areas of activity of citizens who are subject to additional medical examination in accordance with the order of the Ministry of Health of the Russian Federation
List the population groups subject to DLO according to the order of the Ministry of Health of the Russian Federation.
List the main accounting forms for assessing the effectiveness of a local doctor.
Indicate which primary document is issued to the patient by the local doctor if he has indications for sanatorium-resort treatment.
Analysis of population morbidity. Registration of a site passport, planning work for a year, month, quarter. Drawing up reports.
Sections of the annual report.
Concepts of morbidity, morbidity, mortality and mortality.

Literature:
Basic literature:

http://www.studmedlib.ru/.

Further reading:

Baturin V. A. Regular and unwanted effects medications for chronic obstructive pulmonary disease in elderly patients: educational method. manual for clinical doctors. pharmacologists / V. A. Baturin, F. T. Malykhin. -Stavropol: St. State Medical University Publishing House, 2016. - 110 s.

Clinical pharmacology and therapy: scientific and practical journal /Ros. o-therapists. - Published since 1992 - M.: Pharmapress, 1995-
Order of the Ministry of Health of Russia dated December 29, 2012 N 1705n “On the procedure for organizing medical rehabilitation”
Order of the Ministry of Health and Social Development of Russia dated November 22, 2004 N 255 (as amended on December 15, 2014) “On the Procedure for providing primary health care to citizens entitled to receive a set of social services” (together with “Instructions for filling out registration form N 025/u- 04 "Medical record of an outpatient", "Instructions for filling out the registration form N 025-12/у "Outpatient coupon", "Instructions for filling out the registration form N 030/u-04 "Dispensary observation control card", "Instructions for filling out the record Form N 057/u-04 “Referral for hospitalization, rehabilitation treatment, examination, consultation”, “Instructions for filling out registration form N 030-P/u “Passport of the medical district of citizens entitled to receive a set of social services”, “Instructions for filling out registration form N 030-Р/у "Information about medicines issued and released to citizens entitled to receive a set of social services")
Order of the Ministry of Health and Social Development of Russia dated December 14, 2005 N 785 (as amended on April 22, 2014) “On the Procedure for Dispensing Medicines”
Order of the Ministry of Health and Social Development of Russia dated February 12, 2007 N 110 (as amended on February 26, 2013) “On the procedure for prescribing and prescribing medications and products medical purposes and specialized medical nutrition products"
Order of December 20, 2012 No. 1181n “On approval of the procedure for prescribing and prescribing medical products, as well as prescription forms for medical products and the procedure for processing these forms, their recording and storage"
Order of the Ministry of Health of Russia dated December 20, 2012 N 1175n (as amended on April 21, 2016) “On approval of the procedure for prescribing and prescribing medications, as well as forms of prescription forms for medications, order registration of the specified forms, their recording and storage
Order of the Government of the Russian Federation dated December 26, 2015 N 2724-r
from the information bank "Russian Legislation (Prof Version)"
Decree of the Government of the Russian Federation dated December 19, 2015 N 1382 "On the Program of State Guarantees of Free Medical Care to Citizens for 2016"
from the information bank "Russian Legislation (Prof Version)".

We are publishing the full text of the Appeal from 18 local therapists about the failure of the “Moscow Standard Polyclinic” project in the 4th branch of State Budgetary Institution No. 180.

To the head doctor
GBU GP 180 DZM
Vechorko V.I.

Collective appeal

We, doctors and nurses of the State Budgetary Institution 180 DZM, draw your attention to the fact that the Moscow Standard Polyclinic project, implemented under the pretext of “health care optimization” in the State Budgetary Institution 180 DZM, in fact led to a catastrophic situation with the quality of medical care. Changes within the framework of the above project led to the destruction of the fundamental principles of the functioning of the outpatient clinic, namely:

1. The local principle of providing medical care has been destroyed - assigning doctors to certain areas. Patient management by one doctor allows you to effectively assess the dynamics clinical condition, monitor the effectiveness of therapy and be completely immersed in a specific case. The abolition of this principle is destructive, since patients, including With " acute pathology» come for an appointment with the doctor on duty, who often sees them for the first and last time.

2. As part of the project, recording was introduced through the EMIAS system on the “all to all” principle, visits to patients at home by dedicated “mobile teams” were organized, which led to the fact that the patient is often monitored and treated during the course of the disease different people, the overall picture of perceiving the course of the disease and tracking the dynamics of the condition disappears, which leads to a decrease in the effectiveness of treatment and a negative reaction from patients who are not always able to make an appointment with their doctor who is treating a specific case of the disease.

3. The participation of a local nurse in the process of receiving a local general practitioner is regulated by the provisions of Order of the Minister of Health and Social Development dated June 21, 2006 No. 460 “On the organization of the activities of a district nurse.” According to the order, the local nurse, among other things, organizes an outpatient appointment with the local general practitioner, prepares equipment and instruments for work, and provides assistance in the preparation and maintenance of relevant documentation. The participation and assistance of a nurse in the admission process allows the local therapist to focus on working with the patient and increase the efficiency of using working time. We also draw your attention to the fact that the participation of m/s is an integral, integral part of the treatment process both in each specific case and during the entire working time. However, within the framework of the project everything working hours The precinct nurse is devoted to routing patients, the work of the administrator on duty, the work of a consultant at the terminal, and work at the reception desk to collect the cards of patients who have previously made appointments with doctors, which does not leave time for managing the medical area together with the local general practitioner. This not only contradicts employment contracts And job responsibilities nurses, but also radically affects the effectiveness of the work of the local physician.

4. I remind you that in our institution there are standards of 12 minutes per patient appointment, during which it is extremely difficult to simultaneously devote time to both the patient and the independent preparation of medical documentation. Please note that the workload standards for doctors introduced by Order No. 5/1 of 01/09/2015 at City Clinic No. 180 do not correspond to the standards approved by the Ministry of Health of the Russian Federation, and therefore must be changed and brought into line with the standards approved by Order No. 290n.

5. There are no regulations for working with patients with limited mobility. Before the project, the local physician at EMIAS was allocated 2 hours of working time per day to handle calls and monitor low-mobility patients at home.

6. At the same time, within the framework of the “mobile teams” project, since June 2015 they have been working from home with acute cases, periodic visits to patients with limited mobility, not calling a doctor, not provided. The allocation of time to local doctors for (1 hour every 2 days) patronage of patients with limited mobility began only in February 2016.

With such an organization of the treatment process, in addition to a radical decrease in efficiency, there is a decrease in population satisfaction with the quality of the services provided. medical services, other risks arise and materialize:

1. District nurses, with appropriate education and special skills, on the training of which both their personal time and public funds, in fact, are engaged in tasks that do not require special skills and knowledge, which leads to a feeling of decreased self-worth and professional degradation. The elimination of the “registry” with the transition to the work of nurses in the format of a nursing station reduces the “protection of personnel” and makes it impossible to comply with the law on medical confidentiality. As a result, there were cases of spitting, humiliation, threats, and the use of physical force by patients... In addition, nurses are the “first line” when communicating with patients, not protected by windows, which imposes additional “biological” risks. Quantitatively, one nurse at a nursing station processes ~100 people in 6 hours of work, which leads to a constant stressful workload.

2. District doctors work within strict time limits (12 minutes per appointment for 1 person, taking into account the preparation of the relevant medical documentation). At the specified time, without the help of a nurse, it is impossible to devote the necessary time to the patient and at the same time efficiently process medical documentation, which can lead to deterioration in the quality of the process. No additional time is allocated for work. As a result of heavy workloads, there have been a few cases of emergency calls for employees during working hours, followed by emergency hospitalization. As of 02/24/2016, in branch No. 4 the number of local doctors is 12 people (including 2 heads) for 22 sites, excluding those on training, on vacation and on sick leave.

There are violations of current legislation and current regulations:

1. The actual work responsibilities of the nurse contradict the provisions of the order of the Minister of Health and Social Development of June 21, 2006 No. 460 “On the organization of the activities of a district nurse” and the current job descriptions.

2. The actual organization of “nursing posts” leads to a violation of the Constitution of the Russian Federation, Part 1, Article 23, Part 2, Article 24; Part 1 of Article 150 of the Civil Code of the Russian Federation; Article 4, as well as paragraph 7.5 of Article 19 Federal Law Russian Federation of November 21, 2011 “Law on the protection of the health of citizens in the Russian Federation”. since patients will have to publicly, in the presence of other patients, tell medical personnel whose workplace organized in the corridor, about the state of their health. In addition, organizing workplaces in corridors is an infringement of the rights of staff.

3. The standard size of the population supervised by a doctor has been violated, no more than 1900 people per site. The approximate number of the population attached to the branch is 65 thousand people per 10 local physicians, which is more than 3 times the standard load

4. Cases of lengthening the appointment time to 8 hours a day or more transfer the local doctor to the category of a doctor who provides exclusively outpatient appointments. In accordance with the Decree of the Government of the Russian Federation of February 14, 2003 No. 101 “On working hours medical workers depending on their position and (or) specialty,” for medical workers conducting outpatient visits, the following reduced working hours are established depending on their position and (or) specialty: 33 hours per week - according to the list according to Appendix No. 2 .

The above process optimization and constant stress load led to a 2-fold reduction in the number of local physicians in the example of branch No. 4 based on the results of the last 12 months.

In connection with the above, we demand that the work regulations of the local physician and local nurse be brought into compliance with the current regulations, namely:

1. Take measures to eliminate violations of the law in the State Budgetary Institution “City Clinic No. 180 DZM”
2. Issue an order bringing the standards for patient admission in accordance with the requirements of the Ministry of Health.
3. Restore joint appointments between the district physician and the district nurse
4. Establish an appointment based on the duration of the working week of 33 hours in accordance with the Decree of the Government of the Russian Federation of February 14, 2003 No. 101 “On the duration of working hours of medical workers depending on their position and (or) specialty”, for medical workers leading outpatient appointment, the following reduced working hours are established depending on their position and (or) specialty: 33 hours per week - according to the list according to Appendix No. 2.
5. For violation of labor legislation - bring the guilty officials to disciplinary liability
6. For violation of the rights of citizens to provide quality medical care, bring the guilty officials to appropriate disciplinary liability
7. Bring numbers into line medical personnel according to the number of sites and assigned patients based on common sense and in accordance with current regulations.
8. Ensure mandatory daily allocation of time for the local physician to visit low-mobility patients according to the plan
9. Provide the local physician with separate time for maintaining medical records

Please send your response in writing to the chairman of the trade union committee of the primary trade union organization MPRZ “Action” Chatskaya E.A. within 14 calendar days to the address:

Signatures of 18 employees of the 4th branch of the State Budgetary Institution 180 DZM on 2 sheets.