New Forms of Medical Reporting and Filling Thereof in Accordance With Icpc-2 Introduced

Positive changes to the regulatory governing of reporting in healthcare facilities have been made.

On March 13th, 2018 Order of the Ministry of Health “On Amending some Orders of the Ministry of Health of Ukraine” No. 157 as of January 26th, 2018 became effective. The Order repeals outdates and introduces new forms of reporting on healthcare issues.

The following forms expired:

• a voucher for registration of final (updated) diagnoses;
• control ambulatory record;
• student medical record;
• doctor's visit record
• an outpatient patient voucher;
• medical record of a child (for preschool and general educational institutions)
• a book of recording calls of doctors to home.

The Journal of Outpatient Patients Registration (Form N 074 / y), the Register of Patient Visits (Form N 039 / y) and, accordingly, the instructions for filling thereof have been updated and substantially simplified.

It should be noted that the instruction for the Journal of Outpatient Patients Registration stipulates the filling procedure for primary medical care observing the codes of the International Classification of Primary Medical Care ICPC-2-E.

Let us remind you that Order of the Ministry of Health “On some Issues of Applying Ukrainian Version of the International Classification of Primary Medical Care (ICPC-2-E)” No. 13 as of January 4th, 2018 approved the Ukrainian version of ICPC-2-E and the Code Comparison Chart ICPC-2-E, as well as the International Statistical Classification of Diseases and Other Health Problems of the Tenth Revision applied before.

ICPC-2-E is widely spread and applied at providing primary medical care in other countries. In comparison with it the International Statistical Classification of Diseases and Other Health Problems of the Tenth Revision contains a complex system of coding and significantly more codes which are not used at the primary level.

ICPC-2 is based on medical care episode, which is interaction between a patient and a healthcare facility from the first till the last visit to a doctor with one matter. 3 elements are coded for each patient’s visit – the reason for visiting a doctor, diagnosis and actions to be taken.

As the Cabinet of Ministers notes such a system will allow for concentrating at patients’ needs at the primary level, rather than adjust to the code processing to form statistics.