MEDICAL HISTORY MAINTENANCE REQUIREMENTS
The following requirements must be observed when filling in a medical history:
• diagnoses (principal, its complication) are written in Latin transcription;
• results of all tests have a date results of blood, urine and biochemical tests indicate normal values opposite real ones results differing from normal are underlined in red and a medical decision is made on them;
• the treatment sheet indicates the regimen, diet, routes and doses of medications in Latin transcription, dates of prescription and cancellation;
• progress notes reflect the patient's condition, pulse, blood pressure, temperature, complaints, dynamics of the objective and local status and the nature of the performed medical procedures; bandages, punctures, transfusions of blood, its components and blood substitutes; additional prescriptions of medications, procedures and their cancellation, features of the wound process;
• the medical history ends with a stage or discharge epicrisis that indicates the prognosis and recommendations for further treatment, the regimen of work and rest, diet;
• a separate appendix to the medical history contains a report on the differential diagnosis of the underlying surgical disease, taking into account the patient's sex;
• the temperature sheet is correctly filled in with the indication of morning and evening temperatures in the form of a curve, the amount of liquid drunk, daily diuresis, the nature of the stool, the amount and nature of substances separated by drainage or by a nasogastric tub E.