Patient's medical record receiving medical care in a hospital setting. Educational manual

Proper documentation in healthcare is an essential requirement for the quality of medical care, as it has not only therapeutic and diagnostic significance but also legal implications, as it is related to the responsibility of medical personnel for the timeliness and scope of medical care provided. This manual is dedicated to the completion of the accounting form No. 003/u "Medical record of a patient receiving medical care in inpatient conditions, in day hospital conditions," which is the main accounting document of a medical organization providing medical care in inpatient conditions. It summarizes the modern legislative requirements and contains necessary reference information. This manual is intended for physicians of medical organizations of various profiles, healthcare organizers, students studying under basic and additional education programs.