Unofficial translation
In compliance with paragraph 3 of Article 88 of the Code of the Republic of Kazakhstan dated July 7, 2020 "On people's health and the health care system" ORDER:
1. To approve the Rules for organizing the provision of medical care to persons with chronic diseases of the frequency and timing of observation, the mandatory minimum and frequency of diagnostic tests in accordance with Appendix 1 to this order.
2. To recognize as invalid some orders of the Ministry of Health of the Republic of Kazakhstan in accordance with Appendix 2 to this order.
3. The Department of Medical Aid Organization of the Ministry of Health of the Republic of Kazakhstan, in accordance with the procedure established by the legislation of the Republic of Kazakhstan, shall ensure:
1) state registration of this order with the Ministry of Justice of the Republic of Kazakhstan;
2) posting this order on the Internet resource of the Ministry of Health of the Republic of Kazakhstan;
3) within ten working days after the state registration of this order with the Ministry of Justice of the Republic of Kazakhstan, submission to the Legal Department of the Ministry of Health of the Republic of Kazakhstan information on the implementation of the activities provided for in subparagraphs 1) and 2).
4. Control over the implementation of this order shall be entrusted to the supervising Vice-Minister of Health of the Republic of Kazakhstan.
5. This order shall be enforced upon the expiration of ten calendar days after the day of its first official publication.
| The Minister of Healthcare | |
| of the Republic of Kazakhstan | A. Tsoy |
| Appendix 1 to the order of the Minister of the Healthcare of the Republic of Kazakhstan October 23, 2020 № RK MH-149/2020 |
Rules for organizing the provision of medical care to persons with chronic diseases, periodicity and duration of observation, mandatory minimum and frequency of diagnostic tests
Footnote. The rules are in the wording of the order of the Minister of Healthcare of the Republic of Kazakhstan dated 25.09.2024 № 73 (shall be enforced upon expiry of ten calendar days after the day of its first official publication).
Chapter 1. General provisions
1. These Rules for organizing the provision of medical care for persons with chronic diseases, periodicity and duration of observation, mandatory minimum and frequency of diagnostic tests (hereinafter - the Rules) have been developed in accordance with paragraph 3 of Article 88 of the Code of the Republic of Kazakhstan "On Public Health and the Healthcare System" (hereinafter - the Code) and shall determine the procedure for organizing the provision of medical care to persons with chronic diseases.
2. Basic concepts used in these Rules:
1) a list of medicines and medical devices for free and (or) preferential outpatient provision of certain categories of citizens of the Republic of Kazakhstan with certain diseases (conditions) - a list of medicines, medical devices and specialized medical products purchased at the expense of budgetary funds and (or) assets of the social health insurance fund within the framework of the guaranteed volume of free medical care and (or) in the system of compulsory social health insurance in the provision of primary health care and specialized medical care in outpatient settings, including the names and characteristics of medicines, medical devices and specialized medical products in the context of certain categories of citizens of the Republic of Kazakhstan with certain diseases (conditions);
2) a specialized medical practitioner – a medical worker with a higher medical education and a certificate in the field of healthcare;
3) physician (a specialized medical practiotioner) – general practitioner, pediatrician, therapist of a primary health care (hereinafter referred to as PHC) medical organization;
4) dynamic observation – systematic observation of the patient’s health state, as well as provision of necessary medical care based on the results of this observation;
5) electronic register of dispensary patients - an information system of the Ministry of Healthcare of the Republic of Kazakhstan, designed to automate all stages of dispensary observation, including personalized registration of patients suffering from chronic diseases;
6) the authorized body in the field of healthcare (hereinafter - the authorized body) is the central executive body that carries out management and intersectoral coordination in the field of protecting the health of citizens of the Republic of Kazakhstan, medical and pharmaceutical science, medical and pharmaceutical education, sanitary and epidemiological well-being of the population, circulation of medicines and medical devices, quality of medical services (assistance);
7) clinical protocol – scientifically proven recommendations for prevention, diagnosis, treatment, medical rehabilitation and palliative medical care for a specific disease or patient condition;
8) remote medical services – provision of medical services for the purposes of diagnostics, treatment, medical rehabilitation and prevention of diseases and injuries, conducting examinations and assessments using digital technologies, ensuring remote interaction of medical workers with each other, with individuals and (or) their legal representatives, identification of the said individuals, as well as documentation of the actions they perform;
9) medical information system – an information system that ensures the management of processes of healthcare entities in electronic format (hereinafter - MIS);
10) compulsory social health insurance (hereinafter - CSHI) – a set of legal, economic and organizational measures to provide medical assistance to consumers of medical services at the expense of the assets of the social health insurance fund;
11) multidisciplinary group – a group of different specialists formed depending on the nature of the disorder of the functions and structures of the patient’s body and the severity of his/her clinical condition;
12) guaranteed volume of free medical care (hereinafter - GVFMC) – the volume of medical care provided at the expense of budgetary funds;
13) digital healthcare subject – individuals and legal entities, state bodies carrying out activities or entering into public relations in the field of digital healthcare;
14) electronic medical record (hereinafter - the record) – a set of structured personal medical data related to a specific case of medical care.
3. Dynamic monitoring of persons with chronic diseases shall be carried out for the purpose of preventing complications, exacerbations of diseases, their prevention and medical rehabilitation in healthcare organizations providing medical care in outpatient settings, regardless of the form of ownership at the place of attachment to healthcare entities.
4. Dynamic monitoring of individuals with chronic diseases shall be carried out by primary health care specialists and specialized medical practitioners within the framework of the guaranteed volume of medical care and (or) in the compulsory health insurance system in accordance with healthcare standards approved by the authorized body in accordance with subparagraph 32) of Article 7 of the Code.
5. Persons with chronic diseases subject to dynamic observation shall be provided with medicines within the framework of outpatient drug provision (hereinafter - ODP).
6. Persons with chronic diseases shall be subject to registration and further dynamic monitoring by a multidisciplinary group (hereinafter - MDG) in accordance with the conclusion of a primary care physician or an advisory opinion of a specialized medical practitioner (or in accordance with an extract from the medical record of an inpatient).
7. Specialists providing dynamic monitoring in healthcare organizations shall maintain accounting and reporting documentation in accordance with the order of the acting Minister of Healthcare of the Republic of Kazakhstan dated October 30, 2020 № ҚР ДСМ-175/2020 "On approval of forms for accounting documentation in the field of healthcare, as well as instructions for filling them out" (registered in the Register of state registration of regulatory legal acts under № 21579), (hereinafter – the order № ҚР ДСМ-175/2020), by the order of the Minister of Healthcare of the Republic of Kazakhstan dated December 22, 2020 № ҚР ДСМ-313/2020 "On approval of forms for reporting documentation in the field of healthcare" (registered in the Register of state registration of regulatory legal acts under № 21879).
8. The primary care physician examines and assesses the condition of newly diagnosed individuals with chronic diseases who are subject to dynamic monitoring before being registered.
9. Depending on the severity and course of the disease, dynamic monitoring of individuals with chronic diseases shall be carried out by a specialized medical practitioner or a primary care physician:
1) by a specialized medical practitioner – in the presence of complications and progression of diseases with signs of decompensation;
2) by a primary care physician – in the presence of a compensated condition, correctable complications.
10. The periodicity of examinations by a primary care physician, a specialized medical practitioner, or a mid-level medical worker for individuals with chronic diseases, the duration of observation, minimum volume and frequency of diagnostic tests within the framework of dynamic observation shall be carried out:
1) according to the list of chronic diseases subject to dynamic monitoring in primary health care organizations in accordance with Appendix 1 to these Rules;
2) according to the list of chronic diseases subject to dynamic monitoring at the level of consultative and diagnostic care (hereinafter - CDC) in accordance with Appendix 2 to these Rules;
3) according to the list of chronic diseases subject to observation by specialized medical practioners within the framework of the guaranteed volume of medical care and (or) in the compulsory medical insurance system in accordance with Appendix 3 to these Rules.
11. In healthcare organizations, at the outpatient level, dynamic monitoring groups (DMG) shall be created consisting of multidisciplinary specialists under the supervision of a primary care physician or a specialized medical practitioner to carry out dynamic monitoring.
MDG assesses the severity of the patient's chronic disease in order to determine further treatment and monitoring tactics.
12. The members of the MDG shall be approved by the top managers of healthcare organizations and includes specialists to ensure a comprehensive and individual approach to providing medical care to patients with chronic diseases:
primary care physician;
specialized medical practitioners depending on the nature of the patient's illness;
nurses (district, extended practice, general practice);
psychologist;
social worker.
13. At the recommendation of a primary care physician and/or a specialized medical practitioner, the MDG, at least once a quarter, examines patients with complicated and/or atypical course of a chronic disease to determine further observation and treatment tactics.
14. If there are indications (worsening of the clinical picture, negative dynamics in laboratory parameters, changes in instrumental examinations), examination of persons with chronic diseases subject to dynamic observation shall be carried out in excess of the minimum volume and frequency of diagnostic tests, specified in Appendices 1 , 2 and 3 of these Rules in accordance with clinical protocols.
15. Dynamic observation of persons with chronic diseases shall be carried out on a planned basis by organizing an appointment with a specialist, primary care physician, or nurse, regardless of the course of the disease, with preliminary prepared results of laboratory diagnostic services to assess the patient’s condition and carry out the necessary corrective measures (hereinafter - a planned appointment).
16. To conduct a scheduled appointment, an extended practice nurse, a specialized nurse, and a district nurse shall perform:
1) registering patients for an appointment;
2) notification and calling patients via telephone, SMS messages;
3) preparing the patient for the scheduled appointment by prescribing laboratory diagnostic services in accordance with Appendices 1, 2 and 3 of these Rules;
4) monitoring the patient’s progress through the prescribed laboratory diagnostic services and uploading their results;
5) primary interpretation of the results of laboratory diagnostic services;
6) provision of the results of laboratory diagnostic services to a primary care physician or a specialized medical practitioner;
17. At a scheduled appointment, an extended practice nurse, a specialized nurse, and a district nurse shall conduct:
1) nursing examination within the scope of competence (subjective examination: collection of information about the patient’s health state, complaints, life history, disease history and identification of social and psychological risks);
2) objective examination of the patient (measurement of pulse, blood pressure, respiratory rate, height, weight, waist circumference, examination of the skin and visible mucous membranes, including examination of the feet with determination of tactile and pain sensitivity);
3) establishing a nursing diagnosis and performing nursing interventions in accordance with the classifier of nursing diagnoses in accordance with Appendix 4 to these Rules;
4) entering the results of the planned admission into the MIS;
5) assessment of the results of consultative, laboratory and diagnostic tests;
6) issuing prescriptions for medications to continue treatment in accordance with the doctor’s note on the prescription of a course of HBV therapy;
7) organization and control of training of the patient and family members in general care procedures and disease management;
8) referral to a primary care physician or specialist if the patient has complaints or pathological changes based on the results of laboratory diagnostic services;
9) referral to a social worker and/or psychologist if social and psychological risks are identified.
18. As part of dynamic observation, an extended practice nurse, a specialized nurse, and a district nurse shall:
1) provide an explanation to the patient on how to keep a self-monitoring diary in accordance with an individual plan for dynamic monitoring and correction;
2) monitor the patient’s compliance with the individual plan for dynamic observation and correction, and, if necessary, call the patient for a scheduled appointment.
19. At the scheduled appointment, the primary care physician/specialist shall conduct:
1) interview and examination of the patient, including identification of social and psychological risks;
2) assessment of the results of laboratory diagnostic tests;
3) drawing up an individual plan for newly accepted patients;
4) adjustment of the individual plan of non-drug and drug treatment;
5) study and analysis of the patient’s self-monitoring diary;
6) assignment of the minimum scope of examination in accordance with Appendices 1 , 2 and 3 to these rules;
7) additional examinations in accordance with clinical protocols if indicated (in accordance with paragraph 14 of these Rules);
8) referral for inpatient replacement and/or inpatient treatment if signs of exacerbation or progression of the disease are detected, and there are indications for round-the-clock medical supervision and treatment in inpatient conditions;
9) referral for medical rehabilitation in accordance with the order of the Minister of Healthcare of the Republic of Kazakhstan dated April 7, 2023 № 65 “On approval of the standard for organizing the provision of medical rehabilitation” (registered in the Register of state registration of regulatory legal acts under № 32263);
10) providing recommendations to the patient on prevention and a healthy lifestyle;
11) examination of temporary incapacity for work, issuance of a certificate or sheet of temporary incapacity for work in accordance with the order of the Minister of Healthcare of the Republic of Kazakhstan dated November 18, 2020 № ҚР ДСМ-198/2020 "On approval of the rules for conducting an examination of temporary incapacity for work, as well as issuing a certificate or sheet of temporary incapacity for work" (registered in the Register of state registration of regulatory legal acts under № 21660);
12) preparation of documents for referral to a medical and social examination (hereinafter - the MSE), in accordance with the order of the Deputy Prime Minister - Minister of Labor and Social Protection of the Republic of Kazakhstan dated June 29, 2023 № 260 "On approval of the Rules for conducting medical and social examination" (registered in the Register of state registration of regulatory legal acts under № 32922);
13) registration of medical documentation in the MIS. If technically impossible, it is issued in paper form, with subsequent entry into the MIS.
20. As part of dynamic observation, the social worker shall carry out:
1) assessment of the patient’s social status, including his/her living conditions, financial situation, access to healthcare services;
2) supporting patients in accessing social and healthcare services, such as home health care programs, social support;
3) develop a treatment and rehabilitation plan together with the patient and members of the MDG;
4) supporting patients in self-management of their own health, including working with relatives.
21. As part of dynamic observation, the psychologist shall carry out:
1) assessment of the psychological state of patients;
2) psychological support and counselling for patients facing difficulties related to their illness or treatment, including to increase patients’ commitment to self-management;
3) fostering patients’ commitment to healthy behavior;
4) cooperation with specialists within the framework of the MDG to develop a comprehensive approach to the treatment and rehabilitation of patients.
22. Removal from dynamic observation of persons with chronic diseases shall be carried out in the event of:
1) recovery/improvement of the state according to the criteria and observation periods in accordance with Appendices 1, 2 and 3 to these Rules;
2) change of place of attachment to the primary health care organization;
3) failure of the patient to appear for a scheduled appointment for a period of more than 2 years, with an active attraction of a primary health care specialist registered in the MIS
4) death of the patient.
23. Dynamic monitoring of individuals with chronic diseases is carried out within the framework of the disease management program (hereinafter - DMP).
24. Persons with chronic diseases subject to dynamic observation participate in the DMP for three nosologies: arterial hypertension, type 2 diabetes mellitus, and chronic heart failure.
25. The criteria for selecting patients participating in the DMP shall be:
1) patients with primary arterial hypertension (uncomplicated);
2) patients with type 2 diabetes mellitus (glycosylated hemoglobin ≤ 7.0%);
3) patients with chronic heart failure (hereinafter referred to as CHF) of NYHA classes II–IV with an ejection fraction of less than 40% or with an ejection fraction of more than 40% and diastolic dysfunction of the left ventricle according to echocardiography data;
4) patients with risk factors identified during screening (body mass index over 30, smoking, alcohol abuse, adverse heredity, recorded high blood pressure).
26. Patients with several diseases are allowed to participate in the DMP, provided that they meet the selection criteria set out in paragraph 25 of these Rules.
27. The patient is registered in the DMP by the district nurse by entering data into the medical information system.
28. At each appointment, the primary care physician and/or district nurse fills out a checklist of patient’s key data in accordance with clinical protocols, reflecting the results of an objective examination, the date and conclusions of consultations with a general practitioner, therapist, specialized medical practitioner, the results of laboratory and instrumental test methods, and data on the correction of drug therapy for the DMP (hereinafter - the patients’ observation card).
29. Information about the patient, objective examination data, and results of laboratory and instrumental test methods shall be entered into the MNE. The district nurse enters updated MNE information into the DMP register.
30. Based on the data from the DMP patients register, the PHC physician at least once a quarter divides patients’ flows into groups according to their clinical and behavioral characteristics (hereinafter - segmentation), determining the patient’s status according to clinical characteristics:
1) optimal zone (green zone) – when laboratory test results are not higher than the upper limit of the norm;
2) suboptimal (yellow zone) – when laboratory test results exceed the upper limit of the norm by no more than 20%;
3) bad (red) zone - when clinical laboratory test results exceed the upper limit of the norm by more than 20%;
31. According to segmentation, the primary care physician shall determine the frequency of dynamic observation, laboratory and instrumental tests, examinations by specialized medical practitioners in accordance with Appendix 5 to these Rules.
32. Dynamic observation shall be carried out:
1) by a district nurse when the patient is in the optimal zone, through scheduled phone calls, control and monitoring of self-management to maintain normal health indicators;
2) by a primary care physician, if the patient is in a suboptimal zone, dynamic monitoring shall be carried out until the patient’s health improves and clinical and laboratory indicators reach normal levels;
3) by a primary care physician, together with a specialized medical practitioner and other members of the MDG, if the patient is in a bad zone, dynamic observation shall be carried out until the patient’s health improves and clinical and laboratory indicators reach normal levels.
33. During dynamic observation of individuals with chronic diseases within the framework of the DMP, the primary care physician, together with the patient, shall draw up an individual action plan for a short period (no more than 2 weeks), including the amount of physical activity, diet, lifestyle, and elimination of bad habits.
34. The coordinator of the DMP within the primary health care organization area is the primary health care physician.
35. Within the framework of the DMP, the primary health care physician, specialized medical practitioner, an extended practice nurse, district nurse, and a nurse of a specialized medical practitioner shall conduct scheduled appointments in accordance with paragraph 16 of these Rules.
36. An extended practice nurse, a specialized nurse and a district nurse within the framework of a health care institution according to segmentation, shall carry out:
1) organization of the planned appointment of patients participating in the DMP;
2) calling and notification of the date and time of the scheduled appointment via telephone or SMS message;
3) preparing the patient for the scheduled appointment in accordance with Appendices 1, 2 and 3 of these Rules;
4) monitoring the patient’s progress through the prescribed laboratory diagnostic services and uploading their results;
5) collection of information about the patient’s health state, complaints, life history and disease history;
6) examination of the patient (measurement of pulse, blood pressure, respiratory rate, height, weight, waist circumference, examination of the skin and visible mucous membranes, including);
7) examination of the feet with determination of tactile and pain sensitivity in patients with diabetes;
8) conducting a 6-minute walk test in patients with chronic heart failure;
9) establishing a nursing diagnosis in accordance with the classifier of nursing examinations;
10) implementation of nursing interventions in accordance with the established nursing diagnosis;
11) motivational counseling;
12) maintaining feedback with patients;
13) filling in the results of appointment to the register of healthcare institutions and medical information systems.
37. A primary health care physician within the framework of DMP, in accordance with segmentation, shall carry out:
1) examination and interviewing of the patient;
2) evaluation of the results of diagnostic tests;
3) teaching self-management to the patient;
4) formulation, correction and assessment of the implementation of a short individual action plan;
5) motivational counseling;
6) conducting an assessment of the effectiveness of activities carried out as part of the MDG.
38. A specialized medical practitioner shall adjust the individual examination and treatment plan.
39. Within the framework of the DMP, the social worker shall carry out:
1) assessment of the patient’s social status, including his/her living conditions, financial situation, access to health services;
2) supporting patients in accessing social and health services, such as home health care programs, social support;
3) develop a treatment and rehabilitation plan together with the patient and members of the MDG;
4) organizing a telephone call with an invitation to an appointment;
5) supporting patients in self-management of their own health, including working with relatives.
40. Within the framework of the DMP, the psychologist shall carry out:
1) assessment of the psychological state of patients;
2) psychological support and counselling for patients facing difficulties related to their illness or treatment, including to increase patients’ commitment to self-management;
3) fostering patients’ commitment to participation in the Health school activities;
4) cooperation with specialists within the framework of the MDG to develop a comprehensive approach to the treatment and rehabilitation of patients.
41. The patient’s participation in the DMP shall be terminated if complications develop that do not allow the disease to be managed (to achieve target values according to the DMP register) using self-management, motivational counseling, including if the patient refuses.
| Appendix 1 to the Rules for the provision |
|
| of medical care to persons with | |
| chronic diseases, periodicity and duration |
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| of observation, mandatory minimum and |
|
| frequency of diagnostic tests |
List of chronic diseases subject to dynamic monitoring in primary health care organizations
№ | Nosology ICD code | Periodicity of examinations | Minimum laboratory diagnostic tests | Observation periods | ||||||||||
examination of CSF (cerebrospinal fluid) | examination by a primary care physician |
examination by | tests | frequency | ||||||||||
1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | |||||||
Infectious and parasitic diseases | ||||||||||||||
1 | Chronic viral hepatitis B (B18, including B18.0, B18.1, B18.2, B18.8), C and D, without liver cirrhosis | Once a year | Once a year | Twice a year gastroenterologist and/or infectious disease specialist | determination of alanine aminotransferase (ALA) in blood serum | Once a year | lifelong for chronic viral hepatitis B, C (fibrosis stage F2) and D; removal from registration after elimination of the virus for chronic viral hepatitis C (fibrosis stage less than F1) | |||||||
Determination of aspartate aminotransferase (AST) in blood serum | Once a year | |||||||||||||
determination of total bilirubin by fractions in blood serum | Once a year | |||||||||||||
determination of creatinine in blood serum | Once a year | |||||||||||||
determination of AFP in blood serum | Once a year | |||||||||||||
International Normalized Ratio (INR) in serum | Once a year | |||||||||||||
For viral hepatitis B: Polymerase chain reaction for viral hepatitis B (HBV-DNA) quantitative | Once a year | |||||||||||||
quantitative HbsAg ELISA | Once a year | |||||||||||||
For viral hepatitis B: ELISA for hepatitis D | Once a year | |||||||||||||
For viral hepatitis D: PCR for hepatitis D is qualitative | Once a year | |||||||||||||
For viral hepatitis C: PCR for hepatitis C is qualitative | Qualitative PCR: 1) before AVT 2) after AVT; Quantitative PCR: 3) 6 months after AVT (decision on deregistration); If AVT fails, monitoring once every 12 months | |||||||||||||
For viral hepatitis C, PCR for genotype | Before antiviral therapy | |||||||||||||
Ultrasound of abdominal organs | Once a year | |||||||||||||
Indirect elastography (Fibroscan ) of the liver | Once a year | |||||||||||||
Diseases of the circulatory system | ||||||||||||||
2 |
Arterial hypertension: | Once every 3 months - for patients with medium and low risk, once a month - for patients with high and very high risk, and for individuals with low adherence to treatment | Once every 6 months - for patients with medium and low risk, once every 3 months - for patients with high and very high risk, and for individuals with low adherence to treatment |
Once a year | Determination of low density lipoproteins in blood serum | Once a year | for life | |||||||
Determination of creatinine in urine | Once a year | |||||||||||||
Determination of microalbumin in urine | Once a year | |||||||||||||
Electrocardiography in 12 leads with decoding | Once a year | |||||||||||||
hour blood pressure monitoring | Once every 2 years | |||||||||||||
Echocardiography | Once a year | |||||||||||||
3 |
Coronary heart disease: | Twice a year | Twice a year |
Once a year | Determination of low-density lipoproteins in blood serum |
Once every 6 months | for life | |||||||
Determination of creatinine in urine | Once a year | |||||||||||||
Determination of microalbumin in urine | Once a year | |||||||||||||
Echocardiography | Once a year | |||||||||||||
Holter ECG monitoring (24 hours) | Once every 2 years | |||||||||||||
Treadmill test | Once every 2 years | |||||||||||||
3.4. Heart failure, I 50; | Once every 3 months | Once every 3 months |
monthly, | International Normalized Ratio (INR) in serum | Once a week until the target is reached, then once a month; | for life | ||||||||
determination of creatinine in blood serum | the first 3 months - monthly, then once every 3 months; | |||||||||||||
Determination of LDL in blood serum | the first 3 months - monthly, then once every 3 months; | |||||||||||||
Complete blood count 6 parameters with platelet count, bleeding time, blood clotting | Twice a year | |||||||||||||
Determination of creatinine in urine | Once a year | |||||||||||||
Determination of microalbumin in urine | Once a year | |||||||||||||
Echocardiography | the first 3 months - monthly, then once every 6 months; | |||||||||||||
Electrocardiography in 12 leads with decoding | Twice a year the first year, after that, once a year | |||||||||||||
Chest X-ray | Once a year in the first year | |||||||||||||
3.5. Heart failure, I 50 Condition after implantation of a mechanical device, Z 95.8 | Once every 3 months | Once every 3 months |
monthly, | International Normalized Ratio (INR) in serum | 1 time per week until the target is reached, then 1 time per month; | for life | ||||||||
Blood biochemistry: determination of creatinine in blood serum | the first 3 months - monthly, then once every 3 months; | |||||||||||||
Determination of LDL in blood serum | the first 3 months - monthly, then once every 3 months; | |||||||||||||
Complete blood count 6 parameters with platelet count, bleeding time, blood clotting | Twice a year | |||||||||||||
Echocardiography | the first 3 months - monthly, then once every 6 months; | |||||||||||||
Electrocardiography in 12 leads with decoding | Twice a year the first year, after that once a year | |||||||||||||
Chest X-ray | Once in the first year, then by decision of the MDC | |||||||||||||
Ultrasound Doppler of the brachiocephalic trunk | Z95.8 – once in the first year, then by decision of the MDT | |||||||||||||
4 |
Extracranial diseases of the brachiocephalic arteries: | - | Twice a year |
Once a year, | ultrasound dopplerography brachiocephalic trunk | Twice a year | for life | |||||||
4.9 Subarachnoid hemorrhage, I 60 Intracerebral hemorrhage, I 61 Other nontraumatic intracranial hemorrhage, I 62 Ischemic stroke, I 63 Stroke, not specified as hemorrhage or infarction, I 64 | - | Twice a year |
Once a year | General blood test 6 parameters | Twice a year | for life | ||||||||
International Normalized Ratio (INR) | Twice a year | |||||||||||||
Blood biochemistry: determination of low-density lipoproteins in blood serum | Once a year | |||||||||||||
5 |
Heart valve lesions: | Twice a year | Once a year |
Once a year, | Electrocardiography in 12 leads with decoding | Once a year | for life | |||||||
6 | Arrhythmias I47, Atrial fibrillation and flutter, I48 | Twice a year | Twice a year |
Once a year, | Electrocardiography in 12 leads with decoding | Once a year | for life | |||||||
Ultrasound Doppler of the brachiocephalic trunk | Once a year | |||||||||||||
Holter ECG monitoring (24 hours) | Once a year | |||||||||||||
Diseases of the blood and hematopoietic organs | ||||||||||||||
7 |
Hereditary factor VIII deficiency (D66); | Twice a year | Once a year |
Once a year, | General blood test 34 parameters | Once a year | for life | |||||||
Respiratory diseases | ||||||||||||||
8 |
Chronic lower respiratory tract diseases: | Once every 6 months (type A, B, mild, moderate), once every 3 months (type C, D, severe and extremely severe) | Once a year (type A, B, mild, moderate); once every 6 months (type C, D, severe and extremely severe) | Pulmonologist once a year (type A, B, mild, moderate); once every 6 months (type C, D, severe and extremely severe) | Spirography | Once a year | for life | |||||||
Pulse oximetry | At each reception | |||||||||||||
8.2. Asthma, J45 | Once a year (mild), once every 6 months (moderate), once every 3 months (severe) | Once a year (mild), once every 6 months (moderate and severe) |
Once a year, | Spirography | Twice a year | for life | ||||||||
Diseases of the digestive system | ||||||||||||||
9 | Diseases of the upper gastrointestinal tract: | deregistration in the absence of clinical and instrumental signs of the disease for 3 years | ||||||||||||
9.1. Gastroesophageal reflux with esophagitis, K21.0 | 4 times a year | Once a year | Once a year, a gastroenterologist | esophagogastroduodenoscopy | Once a year | |||||||||
9.2. Gastric and duodenal ulcer, K25-K27 | Once a year | histological examination of 1 block-preparation of surgical biopsy material of the 3rd category of complexity | Once a year | |||||||||||
Gastric ulcer, K25 | Twice a year | |||||||||||||
Duodenal ulcer, K26 | Twice a year | |||||||||||||
Peptic ulcer of unspecified site, K27 | Once a year | |||||||||||||
9.3. Chronic atrophic gastritis, K29.4 | Once a year | |||||||||||||
9.4. Polyps ( polyposis ) of the stomach, K31.7 | ||||||||||||||
9.5. Other diseases of the esophagus, K22 | Once a year | |||||||||||||
10 |
Non-infectious enteritis and colitis: | Twice a year | Once a year |
Once a year | esophagogastroduodenoscopy with histological examination of 1 block of surgical biopsy material of 3rd category of complexity | Once a year | for life | |||||||
colonoscopy with histological examination of 1 block of surgical biopsy material of 3rd category of complexity | Once a year | |||||||||||||
11 |
Liver cirrhosis, K70-K76 | Once in 3 months | Once a year | Once a year a gastroenterologist or infectious disease specialist | General blood test 34 parameters with platelets | Child-Pugh Class A. Liver cirrhosis – once every 6 months Child-Pugh Class B and C – once every 3 months | for life | |||||||
determination of alanine aminotransferase (ALA) in blood serum | ||||||||||||||
Determination of aspartate aminotransferase (AST) in blood serum | ||||||||||||||
Determination of bilirubin in blood serum | ||||||||||||||
Determination of creatinine in blood serum | ||||||||||||||
Determination of albumin in blood serum | ||||||||||||||
Determination of sodium in blood serum | ||||||||||||||
Determination of potassium in blood serum | ||||||||||||||
Determination of alpha-fetoprotein (AFP) in blood serum | Once a year | |||||||||||||
International Normalized Ratio (INR) in serum | Once a year | |||||||||||||
Blood test for GGT | Once in 6 months for PBC, biliary cirrhosis | |||||||||||||
Ultrasound of abdominal organs | Once a year | |||||||||||||
Esophagogastroduodenoscopy (in the absence of contraindications) | Once a year | |||||||||||||
Indirect pulse elastometry of the liver | Once a year | |||||||||||||
In case of liver cirrhosis with unspecified formations, dysplastic nodes: Computed tomography of the abdominal cavity with contrast | Once a year | |||||||||||||
Ultrasound of the liver | Once a year | |||||||||||||
Diseases of the musculoskeletal system and connective tissue | ||||||||||||||
12 |
Arthropathy , dorsopathies : | Twice a year | Once a year | Once a year rheumatologist, ophthalmologist | General blood test 6 parameters | Once a year | for life | |||||||
Determination of "C" reactive protein (CRP) in blood serum | Once a year | |||||||||||||
Determination of creatinine in blood serum | Once a year | |||||||||||||
13 |
Systemic connective tissue disorders: | Twice a year | Twice a year | Twice a year rheumatologist | Determination of creatinine in blood serum | Once a year | for life | |||||||
General blood test 6 parameters | Once a year | |||||||||||||
General clinical urine test (General urine analysis) | Once a year | |||||||||||||
Determination of "C" reactive protein (CRP) semi-quantitatively / qualitatively in blood serum | Once a year | |||||||||||||
Diseases of the endocrine system, nutritional disorders and metabolic disorders | ||||||||||||||
14 | Diabetes mellitus type 1 in children E 10 | Once a year | Once a year |
Once a year, | Blood biochemistry: determination of glycated hemoglobin in blood serum | Twice a year | for life | |||||||
determination of blood creatinine with calculation of glomerular filtration rate (GFR) in blood serum | Twice a year | |||||||||||||
Determination of LDL in blood serum | Twice a year | |||||||||||||
Determination of creatinine in urine | Once a year | |||||||||||||
Determination of microalbumin in urine | Once a year | |||||||||||||
Ophthalmoscopy | Once a year | |||||||||||||
Diabetes mellitus type 1 in adults E 10 | Once a year | Once a year |
Once a year | Blood biochemistry: determination of glycated hemoglobin in blood serum | Twice a year | for life | ||||||||
determination of blood creatinine with calculation of glomerular filtration rate (GFR) in blood serum | Twice a year | |||||||||||||
Determination of LDL in blood serum | Twice a year | |||||||||||||
Determination of creatinine in urine | Once a year | |||||||||||||
Determination of microalbumin in urine | Once a year | |||||||||||||
Ophthalmoscopy | Once a year | |||||||||||||
Diabetes mellitus E11-E11.9 | Once a year | Once a year |
Once a year | Blood biochemistry: determination of glycated hemoglobin in the blood, blood creatinine with calculation of glomerular filtration rate (GFR), LDL in the blood serum | Once a year | for life | ||||||||
Determination of creatinine in urine | Once a year | |||||||||||||
Determination of microalbumin in urine | Once a year | |||||||||||||
Ophthalmoscopy | Once a year | |||||||||||||
15 |
Thyroid diseases: | Twice a year | Once a year |
Once a year | Determination of thyroid stimulating hormone (TSH) in blood serum by ELISA method | Once a year | for life | |||||||
Determination of free triiodothyronine (T3) in blood serum by ELISA method | Once a year | |||||||||||||
Determination of free thyroxine (T4) in blood serum by ELISA method | Once a year | |||||||||||||
Diseases of the nervous system | ||||||||||||||
16 | Epilepsy, G 40 (except G40.4) | Once a year | Once a year neurologist | Electroencephalography | Once a year | for life | ||||||||
161 | Other generalized epilepsies and epileptic syndromes (G40.4) | Once a year | Twice a year neurologist | General blood test 34 parameters | Twice a year | for life | ||||||||
Electroencephalography | Once a year | |||||||||||||
17 | Cerebral palsy, G 80 | 4 times a year | Twice a year | Once a year neurologist | GMFCS scale - determination of motor ability in children with cerebral palsy | Twice a year | for life | |||||||
Barthel Activity of Daily Living Index | Twice a year | |||||||||||||
Diseases of the genitourinary system | ||||||||||||||
18 |
Glomerular diseases: | Twice a year | Twice a year | Once a year nephrologist | Determination of creatinine with determination of SCF in blood serum | Once a year | for life | |||||||
determination of creatinine with determination of SCF, total protein in blood serum | Twice a year | |||||||||||||
determination of total protein in blood serum | Twice a year | |||||||||||||
Determination of creatinine in urine | Twice a year | |||||||||||||
Determination of microalbumin in urine | Twice a year | |||||||||||||
Chronic renal failure (N18), | Twice a year | Once a year |
Twice a year | General blood test 6 parameters | Twice a year | for life | ||||||||
General clinical urine test (GCT) | Twice a year | |||||||||||||
Blood biochemistry: determination of serum creatinine with determination of SCF | Twice a year | |||||||||||||
19 | Chronic interstitial nephritis, N11 | 4 times a year | Twice a year | Once a year nephrologist | General clinical urine test (general urine analysis) | Once a year | no recurrence for 3 years | |||||||
20 | Prostatic hyperplasia, N40 | Twice a year | Once a year | Determination of total prostate-specific antigen (PSA) in blood serum by immunochemiluminescence method | Once a year | no recurrence for 3 years | ||||||||
21 | Benign mammary dysplasia, N60 | Twice a year | Once a year | Mammography (4 images), | Once a year | no recurrence for 3 years | ||||||||
Ultrasound examination of mammary glands | Once a year | |||||||||||||
22 |
Non-inflammatory diseases of the female genital organs: | Twice a year | Once a year | Gynecologist once a year | taking a smear for oncocytology | Once a year | 1 year after treatment | |||||||
Gynecological ultrasound ( transvaginal / transabdominal ) | Once a year | |||||||||||||
Benign ovarian neoplasm, D27 | Once every 6 months | Once a year | Gynecologist once a year | ultrasound examination of the pelvis | Once a year | no recurrence for 3 years | ||||||||
Certain conditions arising in the perinatal period | ||||||||||||||
23 | Perinatal onset of bronchopulmonary dysplasia, P27.1 | Once a month up to 1 year, then once every 6 months | for mild severity, once every 6 months up to 1 year, then as needed; for moderate and severe severity, once every 3 months up to 1 year, then up to 3 years, once every 6 months, then once a year | Once a year, a pediatric pulmonologist | computed tomography of the chest and mediastinum | Once a year for 3 years | 3 years, may increase according to indications | |||||||
echocardiography | Once a year for 3 years | |||||||||||||
Congenital anomalies (malformations), deformations and chromosomal disorders (children) | ||||||||||||||
24 |
Congenital heart defects in the postoperative period: | Once a month | Once every 3 months | Once every 3 months by a pediatric cardiologist during the first year of observation, then as indicated | echocardiography | Once every 3 months in the 1st year of observation then once every 6 months | 2 years, but if pulmonary hypertension, residual shunt and valve insufficiency persist - for life | |||||||
Once every 3 months in the 1st year of observation then once every 6 months | ||||||||||||||
25 |
Congenital malformations: | During the first 6 months once a month. Then up to a year, once every 3 months From the 2nd year of life, once every 6 months | Once every 3 months during the 1st year of life; then from the 2nd year of life - once every 6 months | Once a year, a pediatric surgeon | electrocardiographic examination (12 leads) | Once a year | observation up to 3 years of life | |||||||
25.1. esophagogastroduodenoscopy at Q39 | Once a year | |||||||||||||
25.2. chest radiography for Q79 | Once a year | |||||||||||||
25.3. diagnostic calibration bougienage neoanus at Q42 (according to indications) | according to indications | |||||||||||||
Computed tomography of the pelvic organs with contrast | according to indications | |||||||||||||
| Appendix 2 to the Rules for the provision |
|
| of medical care | |
| to persons with chronic diseases, periodicity and duration |
|
| of observation, mandatory minimum and |
|
| frequency of diagnostic tests |
List of chronic diseases subject to dynamic monitoring at the level of consultative and diagnostic care
Item № | Name of diseases | Periodicity of examinations | Minimum laboratory and diagnostic tests | Observation periods | ||||||||||
examination of CSF (cerebrospinal fluid) | examination by a primary care physician | examination by specialized specialists | tests | frequency | ||||||||||
1 | Tuberculosis (A15 - A19) | Once a year | Once a year | examination by a phthisiatrician once every 6 months | Chest X-ray (1 projection) | Once in 6 months | 2 years | |||||||
2 | Human immunodeficiency virus (HIV) disease (B20-B24) | Once a year | Once a year | examination by an infectious disease specialist once every 6 months | Ultrasound of the hepatobiliopancreatic region, chest X-ray | Once a year | for life | |||||||
3 | Malignant and benign neoplasms (C00-97; D00-09; D37-48, except C81-96) | Once a year | Once a year | 1-2 years - once every 3 months, 3-5 years - once every 6 months, then once a year by an oncologist | General blood test 34 parameters | Once a year | for life | |||||||
General clinical urine test (GCT) | Once a year | |||||||||||||
Determination of glucose in blood serum | Once a year | |||||||||||||
determination of direct bilirubin in blood serum | Once a year | |||||||||||||
determination of total bilirubin in blood serum | Once a year | |||||||||||||
determination of alanine aminotransferase in blood serum | Once a year | |||||||||||||
Determination of aspartate aminotransferase in blood serum | Once a year | |||||||||||||
Ultrasound of abdominal organs | Once a year | |||||||||||||
Chest X-ray | Once a year | |||||||||||||
4 | Malignant neoplasms of lymphoid, hematopoietic and related tissues (C81-96) | Once a year | Once a year | 1-2 years - once every 3 months, 3-5 years - once every 6 months, then once a year by an oncologist | General blood test 34 parameters | Twice a year | for life | |||||||
5 | Myelodysplastic syndromes (D46) | Once a year | Once a year | 1-2 years - once every 3 months, 3-5 years - once every 6 months, then once a year by an oncologist, hematologist | General blood test 34 parameters | Twice a year | for life | |||||||
Chronic myeloproliferative disease (D47.1) | ||||||||||||||
6 | Hemolytic anemia (D 56; D 56.0-D 56.2; D 56.4; D 57; D 57.0-D 57.2) | Once a year | Once a year hematologist | General blood test 34 parameters | Twice a year | for life | ||||||||
General clinical urine test (General urine analysis) | Twice a year | |||||||||||||
Determination of direct bilirubin in blood serum | Once a year | |||||||||||||
Once a year an oncologist | Determination of alanine aminotransferase (ALA) in blood serum | Once a year | ||||||||||||
Determination of aspartate aminotransferase (AST) in blood serum | Once a year | |||||||||||||
7 | Paroxysmal nocturnal hemoglobinuria (Marchiafava-Micheli) (D 59.5) | Once a year | Twice a year hematologist | General blood test 34 parameters | Twice a year | for life | ||||||||
Once a year an oncologist | Determination of direct bilirubin in blood serum | Twice a year | ||||||||||||
Determination of osmotic resistance of red blood cells | Once every 2 years | |||||||||||||
Electrophoresis of protein fractions in blood serum and other biological fluids on the analyzer | Once every 2 years | |||||||||||||
Determination of the level of enzymes glucose-6 phosphate dehydrogenase, pyruvate kinase | Once every 2 years | |||||||||||||
Coombs test | Once every 2 years | |||||||||||||
Ultrasound of the hepatobiliopancreatic region (liver, gallbladder, pancreas, spleen) | Once every 2 years | |||||||||||||
8 | Aplastic anemia, unspecified (D 61.9) | Twice a year | Twice a year hematologist | General blood test 34 parameters | Twice a year | for life | ||||||||
9 | Idiopathic thrombocytopenic purpura (D 69.3) | Once a year | Twice a year hematologist | General blood test 34 parameters | Twice a year | for life | ||||||||
Determination of bleeding time | Twice a year | |||||||||||||
Determination of blood clotting time | Twice a year | |||||||||||||
10 | Langerhans cell histiocytosis, not elsewhere classified (D 76.0) | Once a year | Once a year endocrinologist | Complete blood count; Blood biochemistry; | Every 3-6 months | for life | ||||||||
X-ray examination of lesions in bones | Every 3 months | |||||||||||||
Computed tomography of the lungs | Every 6 months | |||||||||||||
Ultrasound of the abdominal cavity | Every 6 months | |||||||||||||
11 | Immunodeficiencies (D80-D84) | Once a year | Twice a year hematologist | General blood test 34 parameters | Twice a year | for life | ||||||||
12 | Diabetes mellitus (E10-E14) | Once a year | Once a year endocrinologist | Blood biochemistry: determination of glycated hemoglobin in blood serum | Twice a year | for life | ||||||||
determination of blood creatinine with calculation of glomerular filtration rate (GFR) in blood serum | Twice a year | |||||||||||||
Determination of LDL in blood serum | Twice a year | |||||||||||||
Determination of creatinine in urine | Once a year | |||||||||||||
Determination of microalbumin in urine | Once a year | |||||||||||||
Ophthalmoscopy | Once a year | |||||||||||||
13 | Other conditions of pituitary hyperfunction (E22.8) | Once a year | Once a year endocrinologist | Determination of prolactin | Once a year | observation for 2 years with stabilization of clinical indicators | ||||||||
Gynecologist once a year | Ultrasound of the pelvic organs | Once a year | ||||||||||||
14 | Hypopituitarism (E23.0) | Once a year | Once a year endocrinologist | Determination of adrenocorticotropic hormone (ACTH) in blood serum by ELISA method | Once a year | for life | ||||||||
15 | Deficiency of other B vitamins (E 53.1) | Once a year | Complete blood count, complete urine analysis | Twice a year | ||||||||||
16 | Classical phenylketonuria (E 70.0) | Once a year | Once a year endocrinologist | General blood test 6 parameters | Twice a year | for life | ||||||||
General clinical urine test (General clinical urine test (General urine analysis)) | Once a year | |||||||||||||
Determination of sodium (Na) in blood serum | Once a year | |||||||||||||
Determination of potassium (K) in blood serum | Once a year | |||||||||||||
17 | Glycogen storage diseases (E 74.0) | Once a year | Once a year endocrinologist | General blood test 6 parameters | Once a year | for life | ||||||||
Determination of glucose in blood serum | Once a year | |||||||||||||
18 | Other sphingolipidoses (E 75.2) | Once a year | Once a year endocrinologist | General blood test 6 parameters | Once a year | for life | ||||||||
General clinical urine test (General urine analysis) | Once a year | |||||||||||||
Determination of total cholesterol in blood serum | Once a year | |||||||||||||
Determination of alanine aminotransferase ( ALA ) in blood serum | Once a year | |||||||||||||
Determination of aspartate aminotransferase ( AST ) in blood serum | Once a year | |||||||||||||
19 | Mucopolysaccharidosis (E 76.0-E 76.2) | Once a year | Once a year endocrinologist | Determination of creatinine in blood serum | Once a year | for life | ||||||||
Determination of total protein in blood serum | Once a year | |||||||||||||
20 | Porphyria (E 80.2) | Once a year | Once a year endocrinologist | General blood test 6 parameters | Once a year | for life | ||||||||
Determination of glucose in blood serum | Once a year | |||||||||||||
21 | Disorders of copper metabolism (E 83.0) | Once a year | Once a year endocrinologist | Blood biochemistry: determination of potassium in blood serum | Once a year | for life | ||||||||
Determination of sodium in blood serum | ||||||||||||||
Determination of chlorides in blood serum | ||||||||||||||
Determination of creatinine in blood serum | ||||||||||||||
Determination of total protein in blood serum | ||||||||||||||
Determination of urea in blood serum | ||||||||||||||
General clinical urine test (General urine analysis) | Twice a year | |||||||||||||
22 | Cystic fibrosis with other manifestations (E 84.8) | Once a year | Once a year endocrinologist | Blood biochemistry: determination of total protein in blood serum | Once a year | for life | ||||||||
Determination of total bilirubin in blood serum | ||||||||||||||
Determination of direct bilirubin in blood serum | ||||||||||||||
Determination of ALT in blood serum | ||||||||||||||
Determination of AST in blood serum | ||||||||||||||
Determination of glucose in blood serum | ||||||||||||||
General clinical urine test (General urine analysis) | ||||||||||||||
23 | Hereditary familial amyloidosis without neuropathy (E 85.0) | Once a year | Once a year endocrinologist | General blood test 6 parameters | Once a year | for life | ||||||||
Determination of total protein in blood serum | Once a year | |||||||||||||
Determination of creatinine in blood serum | Once a year | |||||||||||||
Determination of urea in blood serum | Once a year | |||||||||||||
Ultrasound of the kidneys | Once a year | |||||||||||||
24 | Disorders of plasma protein metabolism (E 88.0) | Once a year | Once a year endocrinologist | General blood test 6 parameters | Once a year | for life | ||||||||
Determination of direct bilirubin in blood serum | Once a year | |||||||||||||
Determination of alanine aminotransferase ( ALA ) in blood serum | Once a year | |||||||||||||
Determination of aspartate aminotransferase ( AST ) in blood serum | Once a year | |||||||||||||
25 | Mental and behavioral disorders (F00-F99) | Once a year | examination by a psychiatrist in accordance with the Standard for the provision of medical and social care in the field of mental health | examination by a psychiatrist in accordance with the Standard for the provision of medical and social care in the field of mental health | examination by a psychiatrist in accordance with the Standard for the provision of medical and social care in the field of mental health | 2 years after stable compensation | ||||||||
26 | Motor neuron disease (G 12.2) | Once a year | Once a year a neurologist | General blood test 6 parameters | Once a year | for life | ||||||||
General clinical urine test (General urine analysis) | Once a year | |||||||||||||
Electroneuromyography | Once a year | |||||||||||||
27 | Degenerative diseases of the nervous system (G30-G32) | Once a year | Once a year a neurologist | General blood test 6 parameters | Once a year | for life | ||||||||
General clinical urine test (General urine analysis) | ||||||||||||||
28 | Demyelinating diseases of the central nervous system (G35-G37) | Once a year | Once a year a neurologist | MRI of the brain | as indicated (once every 2 years) | for life | ||||||||
29 | Other generalized epilepsies and epileptic syndromes (G 40.4) | Once a month |
Once a year, | Electroencephalography | Once a year | clinical and neurophysiological remission for 5 years. | ||||||||
Social adaptation | ||||||||||||||
30 | Encephalopathy, unspecified (G 93.4) | Once a month |
Once a year, | Electrocardiographic examination (12 leads) | as indicated (once every 2 years) | clinical and neurophysiological remission for 5 years. | ||||||||
Ultrasound of the kidneys | social adaptation | |||||||||||||
31 | Acute rheumatic fever (I00-I02) | Twice a year |
Once a year pediatrician, | General blood test 34 parameters | Twice a year | for life | ||||||||
General clinical urine test (General urine analysis) | Once a year | |||||||||||||
Antistreptolysin "O" | Twice a year | |||||||||||||
Electrocardiographic examination (12 leads) | Twice a year | |||||||||||||
32 | Primary pulmonary hypertension (I 27.0) | Twice a year | Once a year cardiologist, pulmonologist | Electrocardiographic examination (12 leads) | Once a year | for life | ||||||||
Echocardiography | Once a year | |||||||||||||
Determination of creatinine in blood serum | Once a year | |||||||||||||
Determination of urea in blood serum | Once a year | |||||||||||||
biochemistry : definition ALT in blood serum | Twice a year | |||||||||||||
Determination of AST in blood serum | Twice a year | |||||||||||||
Determination of direct bilirubin in blood serum | Twice a year | |||||||||||||
Determination of total bilirubin in blood serum | Twice a year | |||||||||||||
Coagulogram: determination of prothrombin time (PT) with subsequent calculation of prothrombin index (PTI) and international normalized ratio (INR) in blood plasma (PT-PTI-INR) | Once a year | |||||||||||||
33 | Other interstitial lung diseases (J 84; J 84.0; J 84.1; J 84.8; J 84.9) | Twice a year | Once a year pulmonologist | General blood test 34 parameters | Once a year | for life | ||||||||
General clinical urine test (General urine analysis) | ||||||||||||||
Spirometry | ||||||||||||||
Chest X-ray | ||||||||||||||
34 | Bullous disorders (L 10; L 13.0) | Once a year | Dermatologist once a year | General blood test 6 parameters | Once a year | for life | ||||||||
35 | Osteogenesis imperfecta (Q 78.0) | 4 times a year | 4 times a year by a pediatric traumatologist in the first year of observation, then as indicated | Determination of calcium (Ca) in blood serum | Once a year | restoration of functional range of motion in the joint | ||||||||
Determination of phosphorus (P) in blood serum | Once a year | |||||||||||||
Radiography of the affected segment | Once a year | |||||||||||||
36 | Congenital ichthyosis (Q 80) | 4 times a year | 4 times a year by a pediatric dermatologist in the first year of observation, then as indicated | General blood test 6 parameters | Once a year | for life | ||||||||
General clinical urine test (General urine analysis) | Once a year | |||||||||||||
37 | Epidermolysis bullosa (Q 81) | Once a year | Dermatologist once a year | General blood test 6 parameters | Once a year | for life | ||||||||
General clinical urine test (General urine analysis) | ||||||||||||||
| Appendix 3 to the Rules for |
|
| provision of medical care to persons with chronic diseases, periodicity and duration |
|
| of observation, mandatory minimum and |
|
| frequency of diagnostic tests |
List of chronic diseases subject to monitoring by specialized medical practitioners within the framework of the guaranteed volume of medical care and (or) in the compulsory health insurance system
Item № | Name of the group of diseases | Periodicity of examinations | Minimum laboratory and diagnostic tests | Observation periods | |||
examination of CSF (cerebrospinal fluid) | examination by a primary care physician | examination by specialized medical practitioners | tests | frequency | |||
Consequences of previous infectious and parasitic diseases | |||||||
1 | Consequences of previous poliomyelitis (B91) | Once a year | Electroneuromyography | Once a year | for life | ||
2 | Condition after surgery for echinococcosis (B67) | Twice a year | Once a year surgeon | Ultrasound of abdominal organs | Once a year | for life | |
Ultrasound of the pleura and pleural cavity | |||||||
Chest X-ray (2 projections) | |||||||
3 | Consequences of previous tuberculosis (B90) | Once a year | Chest X-ray (2 projections) | Twice a year | for life | ||
Diseases of the blood and hematopoietic organs | |||||||
4 | Iron deficiency anemia (D50) | Once in 6 months | Once a year hematologist | General blood test 6 parameters | Once a year | until the indicators are normalized | |
5 | Other hereditary hemolytic anemias (D58) | Once in 6 months | Once a year hematologist | General blood test 34 parameters | Once a year | for life | |
Once a year - oncologist | Determination of direct bilirubin in blood serum | Once a year | |||||
Determination of alanine aminotransferase (ALA) in blood serum | Once a year | ||||||
Determination of aspartate aminotransferase (AST) in blood serum | Once a year | ||||||
6 | Acquired hemolytic anemia (D59, except D59.5) | Once in 6 months | Twice a year hematologist | General blood test 34 parameters | Twice a year | for life | |
Once a year - oncologist | Determination of direct bilirubin in blood serum | Twice a year | |||||
Determination of osmotic resistance of red blood cells | Once every 2 years | ||||||
Electrophoresis of protein fractions in blood serum and other biological fluids on the analyzer | Once every 2 years | ||||||
Determination of the level of enzymes glucose-6 phosphate dehydrogenase , pyruvate kinase | Once every 2 years | ||||||
Coombs test | Once every 2 years | ||||||
Ultrasound of the hepatobiliopancreatic region (liver, gallbladder, pancreas, spleen) | Once every 2 years | ||||||
7 | Acquired pure red cell aplasia ( erythroblastopenia ) (D60), other aplastic anemias (D61, except D 61.9 ), Acute posthemorrhagic anemia (D62), Anemia in neoplasms (D63) | Once in 6 months |
Twice a year hematologist, | General blood test 34 parameters | Twice a year | for life | |
Diseases of the endocrine system, nutritional disorders and metabolic disorders | |||||||
8 | Other forms of hypothyroidism (E03), Other forms of nontoxic goiter (Nodular and mixed euthyroid goiter after surgery) (E04) | Once a year |
Once a year | Determination of free triiodothyronine (T3) in blood serum by ELISA method | Once a year | for life | |
Determination of free thyroxine (T4) in blood serum by ELISA method | Once a year | ||||||
Determination of antibodies to thyroid peroxidase (a-TPO) in blood serum by ELISA method | Once a year | ||||||
Thyroid ultrasound | Once a year | ||||||
Electrocardiographic examination (12 leads) with decoding | Once a year | ||||||
9 | Hypoparathyroidism (E20) | Once a year |
Once a year | Determination of parathyroid hormone in blood serum by ELISA method | Once a year | for life | |
Determination of calcium ( Ca ) in blood serum | Once a year | ||||||
Determination of phosphorus (P) in blood serum | Once a year | ||||||
10 | Hyperfunction of the pituitary gland (E22, except E 22.8) | Once a year |
Once a year | Determination of prolactin | Once a year | observation for 2 years with stabilization of clinical indicators | |
Gynecologist once a year | Ultrasound of the pelvic organs | Once a year | |||||
11 | Hypofunction and other disorders of the pituitary gland (E 23, except E 23.0) Diabetes insipidus (E23.2) | Once a year |
Once a year | Determination of adrenocorticotropic hormone (ACTH) in blood serum by ELISA method | Once a year | for life | |
12 | Cushing syndrome (E24) | Once a year |
Once a year | Determination of cortisol in blood serum by immunochemiluminescence method | Once a year | for life | |
Determination of glucose in blood serum | Once a year | ||||||
X-ray of the thoracic spine | Once a year | ||||||
X-ray of the lumbosacral spine | Once a year | ||||||
Ultrasound of the adrenal glands | Once a year | ||||||
13 | Adrenogenital disorders (E25) | Once a year | Once a year endocrinologist, urologist | observation for 5 years with stable remission | |||
14 | Ovarian dysfunction (E28) | Once a year | Determination of thyroid stimulating hormone (TSH) in blood serum | Once a year | observation for 3 years with stable remission, improvement of clinical indicators | ||
Determination of follicle-stimulating hormone (FSH) in blood serum | Once a year | ||||||
Determination of luteinizing hormone (LH) in blood serum | Once a year | ||||||
15 | Disorders of puberty, not elsewhere classified (E30) | Once a year | Once a year gynecologist, endocrinologist | Determination of thyroid stimulating hormone (TSH) in blood serum | Once a year | observation for 3 years with stable remission, improvement of clinical indicators | |
Determination of follicle-stimulating hormone (FSH) in blood serum | Once a year | ||||||
Determination of luteinizing hormone (LH) in blood serum | Once a year | ||||||
16 | Other endocrine disorders (E34) | Once a year |
Once a year | Determination of thyroid stimulating hormone (TSH) in blood serum | Once a year | observation for 3 years, removal in case of stable remission, improvement of clinical indicators | |
Determination of follicle-stimulating hormone (FSH) in blood serum | Once a year | ||||||
Determination of luteinizing hormone (LH) in blood serum | Once a year | ||||||
17 | Vitamin D deficiency (E55) | Once a year | 1x per year orthopedic surgeon | Biochemical blood test for calcium and phosphorus | Twice a year | within three years | |
Diseases of the genitourinary system | |||||||
18 | Prolapse of female genital organs (N81) | Once a year | Smear for oncocytology | Once every 2 years | until complete recovery | ||
Ultrasound of the pelvic organs | Once a year | ||||||
19 | Absence of menstruation, scanty and rare menstruation (N91) | Once a year | Once a year obstetrician-gynecologist | Determination of thyroid stimulating hormone (TSH) in blood serum | Once a year | restoration of menstrual function | |
Determination of follicle-stimulating hormone (FSH) in blood serum | Once a year | ||||||
Determination of luteinizing hormone (LH) in blood serum | Once a year | ||||||
20 | Other abnormal bleeding from the uterus and vagina (N93) | Once a year | Once a year obstetrician-gynecologist | General blood test 6 parameters | Once a year | restoration of menstrual function | |
Determination of thyroid stimulating hormone (TSH) in blood serum | Once a year | ||||||
Determination of follicle-stimulating hormone (FSH) in blood serum | Once a year | ||||||
Determination of luteinizing hormone (LH) in blood serum | Once a year | ||||||
21 | Female infertility (N97) | Once a year | Once a year obstetrician-gynecologist | Smear for oncocytology | Once a year | restoration of fertility | |
Ultrasound of the pelvic organs | Once a year | ||||||
Diseases of the nervous system | |||||||
22 | Sequelae of inflammatory diseases of the central nervous system (G09) | Once in 6 months | ophthalmoscopy | Once a year | observation until full or partial restoration of functions is achieved | ||
23 | Parkinson's disease (G20) | Once a year | Once a year a neurologist | for life | |||
24 | Other degenerative diseases of the basal ganglia (G23) | Once a year | for life | ||||
25 | Migraine (G43) | Once a year | Once a year a neurologist | observation until complete or partial restoration of functions: improvement of quality of life | |||
26 | Trigeminal nerve disorders (G50) | Once a year | Once a year a neurologist | observation for 1 year subject to regression and/or stabilization of neurological symptoms | |||
27 | Facial nerve lesion (G51) | Once a year | Once a year a neurologist | observation for 1 year subject to regression and/or stabilization of neurological symptoms | |||
28 | Disorders of other cranial nerves (G52) | Once a year | Once a year a neurologist | observation for 1 year subject to regression and/or stabilization of neurological symptoms | |||
29 | Disorders of nerve roots and plexuses (G54) | Once a year | Once a year a neurologist | observation for 1 year subject to regression and/or stabilization of neurological symptoms | |||
30 | Myasthenia gravis and other disorders of the neuromuscular junction (G70.0-G70.9) | Twice a year | Once a year a neurologist | Electroneuromyography | Once a year | for life | |
31 | Other diseases of spinal cord (G95) | Once a year | Once a year a neurologist | General blood test 6 parameters | Once a year | for life | |
Eye diseases | |||||||
32 | Iridocyclitis (H20) | Once a year | Once a year ophthalmologist | Tonometry | Once a year | relief of the inflammatory process | |
Biomicroscopy | Once a year | ||||||
33 | Chorioretinal dystrophies (after laser surgery) (H32) | Once a year | Once a year ophthalmologist | Visometry | Once a year | for life | |
34 | Retinal detachment and retinal tears (H33) | Once a year | Once a year ophthalmologist | Perimetry | Once a year | for life | |
Once a year a neurologist | Ophthalmoscopy | Once a year | |||||
Biomicroscopy of the eye | Once a year | ||||||
Optical coherence tomography | Once a year | ||||||
Cycloscopy | Once a year | ||||||
Ultrasound of the eyeball | Once a year | ||||||
35 | Retinal vascular occlusions (H34) | Once a year | for life | ||||
36 | Other diseases of retina (H35) | Once a year | for life | ||||
37 | Diseases of the eyeball (H44) | Once a year | Once a year ophthalmologist | Visometry | Once a year | for life | |
Perimetry | Once a year | ||||||
38 | Glaucoma (H40) | Once a year | Once a year ophthalmologist | Daily tonometry (non-contact) (1 eye) | Once a year | for life | |
Unloading and loading tests for glaucoma (1 eye) | Once a year | ||||||
Perimetry | Once a year | ||||||
Keratometry | Once a year | ||||||
Gonioscopy | Once a year | ||||||
39 | Refractive errors and accommodation (H52) | Once a year | improving visual acuity | ||||
40 | Visual disturbance (H53) | Once a year | improving visual acuity | ||||
Diseases of the hearing organs | |||||||
41 | Conductive and sensorineural hearing loss (H90) | Once a year |
Once a year | Pure Tone Threshold Audiometry | Once a year | for life | |
Diseases of the circulatory system | |||||||
42 | Cardiomyopathy (I42) | Once in 6 months | Once a year a cardiologist | General clinical urine test (GCT) | Once a year | for life | |
Electrocardiographic examination (12 leads) | Twice a year | ||||||
Echocardiography | Once a year | ||||||
43 | Atrioventricular block and left bundle branch block ( I44) | Once in 6 months | Once a year a cardiologist | Electrocardiographic examination (12 leads) with decoding | Once a year | until complete recovery and no recurrence for 5 years | |
44 | Atrioventricular block and right bundle branch block (I45) | Once in 6 months | Once a year a cardiologist | Electrocardiographic examination (12 leads) with decoding | Once a year | until complete recovery and no recurrence for 5 years | |
45 | Hereditary and idiopathic neuropathy (G60) | Once a year | General blood test 6 parameters | Once a year | for life | ||
46 | Diseases of capillaries (I78) | Once a year | Once a year hematologist, rheumatologist, vascular surgeon (as indicated) | General blood test 6 parameters | Once a year | until complete recovery and no recurrence for 5 years | |
General clinical urine test (general urine analysis) | Once a year | ||||||
47 | Atherosclerosis (I70) | Once a year | Once a year surgeon | Determination of low-density lipoproteins in blood serum | Once a year | for life | |
48 | Aneurysm and dissection of the aorta (I71) | Twice a year | Once a year, an angiosurgeon | Ultrasound Doppler of the abdominal aorta and its branches | Once a year | for life | |
49 | Other peripheral vascular diseases (I73) | Once a year | Once a year a surgeon or vascular surgeon | observation for 3 years in the absence of signs of disease progression | |||
50 | Other disorders of arteries and arterioles (I77) | Once a year | Once a year a surgeon or vascular surgeon | observation for 1 year in the absence of signs of disease progression | |||
51 | Phlebitis and thrombophlebitis (I80) Postphlebitic syndrome (I87) Varicose veins of the lower extremities (I83) | Once a year | Once a year surgeon, vascular surgeon | Ultrasound Doppler of the veins of the lower extremities | Once a year | observation for 2 years in the absence of signs of disease progression | |
Respiratory diseases | |||||||
52 | Emphysema of the lung (J43.9) | Once a year | Once a year surgeon, pulmonologist | Spirometry | 1 time per year | for life | |
Diseases of the digestive system | |||||||
53 | Other diseases of the esophagus (K22) | 4 times a year | Once a year | Once a year gastroenterologist | observation until stable remission is achieved | ||
54 | Hernias of the anterior abdominal wall (K40-43.9): | Once a year | observation until the hernia is eliminated | ||||
55 | Gallstone disease (K80) Chronic cholecystitis (K81) | Once a year | observations until gallbladder removal , achieving stable remission | ||||
Diseases of the skin, subcutaneous tissue | |||||||
56 | Atopic dermatitis (L20) | Once a year | Dermatologist once a year | General urine analysis | Once a year | observation for 5 years with complete recovery and no recurrence | |
57 | Psoriasis (L40) | Once a year | Dermatologist once a year | General blood test 6 parameters | Twice a year | observation for 5 years with complete recovery and no recurrence | |
General clinical urine test (General urine analysis) | Twice a year | ||||||
Blood biochemistry: determination of alanine aminotransferase ( ALA ), | Once a year | ||||||
Determination of aspartate aminotransferase ( AST ) in blood serum | Once a year | ||||||
Determination of total bilirubin in blood serum | Once a year | ||||||
Determination of direct bilirubin in blood serum | Once a year | ||||||
Determination of glucose in blood serum | Once a year | ||||||
58 | Erythema multiforme (L51) | Once a year | General blood test 6 parameters | Once a year | observation for 5 years with complete recovery and no recurrence | ||
General urine analysis | Once a year | ||||||
Determination of direct bilirubin in blood serum | Once a year | ||||||
59 | Granulomatous changes of the skin and subcutaneous tissue (L92) | Once a year | Dermatologist once a year | General blood test 6 parameters | Once a year | observation for 5 years with complete recovery and no recurrence | |
60 | Lupus erythematosus (L93) | Once a year | General blood test 6 parameters | Once a year | for life | ||
61 | Other diseases of the skin and subcutaneous tissue, not elsewhere classified (L98) | Once a year | Dermatologist once a year | for life | |||
62 | Facultative and obligate precancers of the skin; cutaneous horn, cysts, radiation dermatitis, xeroderma pigmentosum, Paget's disease , Bowen's disease , (L85.8, L72.9, L58, Q82.1, M88, L90, L91) | Once a year | Dermatologist once a year | General blood test 6 parameters | Once a year | observation for 5 years with complete recovery and no recurrence | |
Diseases of the musculoskeletal system | |||||||
63 | Arthrosis (M15-M19) | Once a year | Twice a year traumatologist-orthopedist | X-ray of the affected joints | Once a year | reduction of pain syndrome, signs of inflammation | |
64 | Consequences of trauma - contractures, ankylosis in a vicious position, osteomyelitis in adults (M21) | Once a year | Once a year, traumatologist-orthopedist | General blood test 6 parameters | Once a year | improving the functional range of motion in joints | |
Radiography of the affected segment | Once a year | ||||||
65 | Osteopathy and chondropathy (M80-M94) | Once a year | Twice a year traumatologist-orthopedist | General blood test 6 parameters | Once a year | observation for 3 years in the absence of exacerbation | |
Radiography of the affected segment | Once a year | ||||||
Lesions in the perinatal period | |||||||
66 | Subdural hemorrhage due to birth injury (P10.0) | Twice a year | Twice a year neurologist | observation until full or partial restoration of functions is achieved | |||
67 | Birth injury of the peripheral nervous system (P14) | Twice a year | Twice a year neurologist | observation until full or partial restoration of functions is achieved | |||
Congenital anomalies (malformations) of the eye, ear, face and neck | |||||||
68 | Microcephaly (Q2) | Once a year | Twice a year neurologist | observation until full or partial restoration of functions is achieved | |||
69 | Anophthalmos, microphthalmos and congenital macrophthalmos , after removal of eyes due to other ophthalmopathology, (Q11) | Once a year | Once a year ophthalmologist | Ophthalmoscopy | Once a year | for life | |
Perimetry | Twice a year | ||||||
70 | Congenital malformations of the ear causing hearing impairment (Q16) | Once a year |
Once a year | Pure Tone Threshold Audiometry | Once a year | for life | |
71 | Congenital clefts of palate and lip (Q35-Q37) | from birth to 6 months monthly, from 6 months to 6 years once every two months and according to indications |
Once a year | General blood test 6 parameters | Once a year | deregistration after restoration of anatomical integrity of tissues | |
Determination of total protein in blood serum | Twice a year | ||||||
72 | Congenital malformations and deformities of the musculoskeletal system (Q65-Q79) | Once a year | Once a year, traumatologist-orthopedist | Radiography of one segment | Once a year | restoration of functional range of motion in the joint | |
Injuries | |||||||
73 | Head injuries (S06) | Twice a year | observation until full or partial restoration of functions is achieved | ||||
74 | Trauma of abdomen, lower back, lumbar spine and pelvis (S30-S39) | Once a year | Once a year, traumatologist-orthopedist | Control radiographs of the affected segment | at 6, 12 and 36 weeks after surgery | observation until full or partial restoration of functions is achieved | |
CT scan of the spine | as indicated (once every 3 years) | ||||||
Condition after organ and tissue transplantation | |||||||
75 | Presence of transplanted organs and tissues (Z94) | Once per month | Specialist according to indications | General blood test 34 parameters | 1 time per month | for life | |
General clinical urine test (GCT) | 1 time per month | ||||||
Serum tacrolimus/CsA level | 1 time per month (up to 12 months) | ||||||
Pregnancy, childbirth and the postpartum period | |||||||
76 | Pregnancy-induced hypertension without significant proteinuria, O13 | Once per month | Once per month | General blood test 6 parameters | Once a year | during pregnancy | |
General clinical urine test (GCT) | Once a year | ||||||
Determination of daily proteinuria in urine | Once a year | ||||||
determination of creatinine in blood serum | Once a year | ||||||
determination of urea in blood serum | Once a year | ||||||
determination of alanine aminotransferase ( ALA ) in blood serum | Once a year | ||||||
Determination of aspartate aminotransferase ( AST ) in blood serum | Once a year | ||||||
Determination of direct bilirubin in blood serum | Once a year | ||||||
Determination of indirect bilirubin in blood serum | Once a year | ||||||
77 | Diabetes mellitus originating during pregnancy O24.4, Diabetes mellitus in pregnancy, unspecified O24.9 | Once a month | Once a month | General blood test 6 parameters | Once a year | during pregnancy | |
General clinical urine test (GCT) | Once a year | ||||||
Determination of glycated hemoglobin in blood serum | Once a year | ||||||
78 | Rhesus immunization requiring medical care for the mother O36.0 | Once a month | Once a month | Examination of the Rh factor of the fetus in Rh-negative women from 9 weeks to 13 weeks using the molecular genetic method of examining venous blood. | Once during pregnancy | during pregnancy | |
If the fetus is Rh-positive, determine the titer of anti-erythrocyte antibodies using the indirect Coombs test. | Once a month | ||||||
| Appendix 4 to the Rules for the provision |
|
| of medical care to persons | |
| with chronic diseases, periodicity and duration |
|
| of observation, mandatory minimum | |
| and frequency of diagnostic studies |
Table 1. Classification of nursing diagnoses
A. | PHYSICAL ACTIVITY COMPONENT |
A01.2 | Risk of inability to perform daily activities - A01.2 |
A02.0 | Changes in the musculoskeletal system - |
B. | COMPONENT GASTROINTESTINAL TRACT |
B03.0 | Changes in bowel movements |
B03.1 | Fecal incontinence |
B03.4 | Intestinal obstruction |
B03.5 | Decreased frequency of bowel movements |
C. | COMPONENT CARDIOVASCULAR SYSTEM |
C05.0 | Change in cardiac output |
C06.0 | Cardiovascular changes |
C06.2 | Risk of bleeding |
D. | COGNITIVE / NEUROLOGICAL COMPONENT |
D07.0 | Cerebral changes |
D07.1 | Confusion |
D08.0 | Lack of knowledge |
D08.1 | Lack of knowledge about diagnostic tests |
D08.2 | Lack of knowledge about diet |
D08.3 | Lack of knowledge about the disease |
D08.4 | Lack of knowledge about the amount of liquid |
D08.5 | Lack of knowledge about taking medications |
D08.7 | Lack of knowledge about treatment |
D09.0 | Changes in the thinking process |
D09.1 | Memory impairment |
E. | COMPONENT OF PSYCHOLOGICAL ADAPTATION |
E11.0 | Decreased ability to cope with family difficulties |
E11.2 | Inability to overcome family difficulties |
E12.0 | Individual problems with overcoming difficulties |
E12.1 | Adaptation disorder |
E12.2 | Problems with decision making |
E12.3 | Protective adaptation |
E12.4 | Trying to reduce anxiety/worry |
E13.0 | Post-traumatic reaction |
E13.1 | Traumatic syndrome associated with violence |
E14.0 | Change of spiritual state |
E14.1 | Mental fatigue |
E52.0 | Violation of social adaptation |
E53.0 | Sorrow |
E53.1 | Premonition of grief |
E53.2 | Dysfunctional Grief |
F. | COMPONENT VOLUME OF LIQUID |
F15.0 | Change in liquid volume |
F15.1 | Fluid volume deficit |
F15.2 | Risk of fluid volume deficit |
F15.3 | Excess fluid volume |
F15.4 | Risk of excess fluid volume |
F62.0 | Electrolyte imbalance |
H. | MEDICINAL COMPONENT |
H21.0 | Risk of side effects from taking a drug |
H21.1 | Polypharmacy |
I. | METABOLISM COMPONENT |
I22.0 | Endocrine changes |
I23.0 | Diseases of the immune system |
J. | POWER COMPONENT |
J24.0 | Change in diet |
J24.1 | Malnutrition |
J24.2 | Risk of malnutrition |
J24.3 | Overnutrition |
J24.4 | Risk of overnutrition |
J24.5 | Swallowing disorder |
K. | COMPONENT OF REGULATION OF PHYSICAL PROCESSES |
K25.0 | Somatic condition of the patient |
K25.1 | Spinal cord injury |
K25.2 | Hyperthermia |
K25.3 | Hypothermia |
K25.4 | Violation of thermoregulation |
K25.5 | Risk of infection |
K25.6 | Infection |
K25.7 | Changes in the patient's condition with intracranial pressure |
L. | COMPONENT OF THE RESPIRATORY SYSTEM |
L26.0 | Change in breathing |
L26.1 | Airway obstruction |
L26.2 | Respiratory failure |
L26.3 | Violation of gas exchange |
L56.0 | Violation of pulmonary ventilation |
M. | RELATIONSHIP COMPONENT |
M27.3 | Sexual dysfunction |
M27.4 | Obsessive concern for another person |
M28.0 | Difficulties in communication |
M28.1 | Inability to express one's thoughts when speaking |
M29.0 | Stable marriage or loneliness |
M31.0 | Changes in sexual life |
M32.0 | Disorders of personality development |
M32.1 | Violation of the interrelationship of personal relationships |
M32.2 | Isolation from society |
M32.3 | Difficulty in parting with the past (housing, household items) |
N. | SECURITY COMPONENT |
N33.0 | Risk of injury |
N33.1 | Risk of aspiration |
N33.2 | Immobilization syndrome |
N33.3 | Risk of poisoning |
N33.4 | Risk of suffocation |
N33.5 | Risk of injury |
N33.6 | Risk of falling |
N34.0 | Risk of violence |
N34.1 | Suicidal risk |
N34.2 | Risk of self-harm |
N57.0 | Risk of postoperative complications |
N57.1 | Postoperative complications |
N57.2 | Disruption of the body's condition with delayed recovery after surgery |
N58.0 | Drug Abuse/Substance Abuse |
N58.1 | Tobacco use |
N58.2 | Alcohol use/Alcoholism |
N58.3 | Drug Use/Drug Addiction |
O. | SELF-CARE COMPONENT |
O38.1 | Changes in life processes |
P. | SELF-ASSESSMENT COMPONENT |
P40.0 | State of worry and anxiety |
P41.0 | State of feeling fear |
P42.0 | Inability to assess a situation or problem |
P42.1 | Hopelessness/Despair |
P42.2 | Powerlessness/Helplessness |
P43.0 | Inability to personally evaluate oneself |
P43.1 | Disturbance of body perception- |
P43.2 | Mental personality disorder |
P43.3 | Conscious or subconscious belittling of one's capabilities, merits and talents |
P43.4 | Negative self-esteem towards oneself and one's abilities |
Q. | SENSOR COMPONENT |
Q44.0 | Sensory perception disorder |
Q44.1 | Hearing impairment |
Q44.2 | Taste disturbance |
Q 44.3 | Disturbances in the state of the body during kinesthetic perception |
Q44.4 | Disturbance of the body's condition with changes in the sense of smell |
Q44.5 | Disturbances in the state of the body with impaired tactile sensations |
Q44.6 | Disorders of the body's condition in motor and sensory functions |
Q44.7 | Disturbances in the body's condition with changes in vision |
Q45.0 | Disturbance of the body's condition with a change in the feeling of comfort |
Q63.0 | Pain |
Q63.1 | Acute pain |
Q63.2 | Chronic pain |
R. | SKIN INTEGRITY COMPONENT |
R46.0 | Changes in the integrity of the skin |
R46.1 | Disorder of the oral mucosa |
R46.2 | Violation of the integrity of the skin |
R46.3 | Risk of damage to the integrity of the skin |
R46.4 | Violation of the integrity of the skin during surgical intervention |
R46.5 | Disruption of the body's condition in case of allergy to latex |
R47.0 | Peripheral changes |
S. | TISSUE PERFUSION COMPONENT |
S48.0 | Disruption of the body's condition due to problems with tissue oxygenation , including the circulatory and vascular systems |
T. | COMPONENT OF THE UROGENITAL SYSTEM |
T49.0 | Disruption of the body's condition due to changes in the genitourinary system |
T49.1 | Disturbance of the body's condition in functional incontinence |
T49.2 | Disturbance of the body's condition with reflex urinary incontinence |
T49.3 | Disturbance of the body's condition with urinary incontinence under stress or tension |
T49.5 | Disturbance of the body's condition in imperative urinary incontinence |
T49.6 | Disturbance of the body's condition due to urinary retention |
T50.0 | Disruption of the body's condition due to impaired renal function |
U. | REPRODUCTIVE HEALTH COMPONENT |
U59.0 | Reproductive health risk |
U59.1 | Risk of childbearing age |
U59.2 | Risk of infertility |
U59.3 | Risks associated with contraception |
U60.0 | Perinatal risk |
U60.1 | Threat of pregnancy |
U60.2 | Threat in childbirth |
U60.3 | Threat at birth |
Table 2. Classification of nursing interventions
B. | COMPONENT GASTROINTESTINAL TRACT |
B06.0 | Bowel care |
B06.0.1 | Assessment of the scope of measures/actions to control and restore bowel function |
B06.0.2 | Implementation of measures to control and restore bowel function |
B06.0.3 | Training in measures to control and restore bowel function |
B06.0.4 | Coordination of activities to monitor and restore bowel function or adjust nursing interventions |
B06.1 | Preparing the intestines for removal |
B06.1.1 | Assessment of the scope of activities/actions to prepare the intestines for removal |
B06.1.2 | Carrying out measures to prepare the intestines for removal |
B06.1.3 | Teach the procedures for performing bowel preparation for removal |
B06.1.4 | Coordination of activities for the implementation of bowel preparation for removal or correction of nursing interventions |
B06.3.0 | Enema |
B06.3.1 | Assessment of the volume of activities/actions for performing rectal administration of liquid |
B06.3.2 | Carrying out activities for the implementation of rectal administration of liquid |
B06.3.3 | Teach procedures for administering rectal fluids |
B06.3.4 | Coordination of activities for the implementation of rectal fluid administration or correction of nursing interventions |
B07.0 | Caring for a bowel stoma |
B07.0.1 | Assessment of the scope of activities/actions for performing intestinal stoma care |
B07.0.2 | Carrying out measures for the care of the intestinal stoma |
B07.0.3 | intestinal stoma care procedures |
B07.0.4 | Coordination of activities for the implementation of intestinal stoma care or adjustment of nursing interventions |
B07.1 | Flushing of the intestinal stoma |
B07.1.1 | Assessment of the scope of activities/actions to perform intestinal stoma cleansing |
B07.1.2 | Carrying out measures to cleanse the intestinal stoma |
B07.1.3 | bowel stoma cleansing procedures |
B07.1.4 | Coordination of activities to carry out bowel stoma cleansing or correction of nursing interventions |
B62.0 | Stomach care |
B62.0.1 | Assessment of the scope of activities/actions for the implementation of gastric care |
B62.0.2 | Carrying out activities to care for the stomach |
B62.0.3 | Teach activities to carry out gastric care |
B62.0.4 | Coordination of gastric care activities or adjustment of nursing interventions |
C. | COMPONENT CARDIOVASCULAR SYSTEM |
C08.1 | Cardiological rehabilitation |
C08.1.1 | Assessment of the scope of activities/actions to restore heart rhythm |
C08.1.2 | Carrying out measures to restore heart rhythm |
C08.1.3 | Teach heart rhythm restoration activities |
C08.1.4 | Coordination of cardiac rhythm restoration activities or correction of nursing interventions |
C09.0 | Caring for a pacemaker |
C09.0.1 | Assessment of the scope of activities/actions for pacemaker care |
C09.0.2 | Carrying out measures for the care of a pacemaker |
C09.0.3 | Teach pacemaker care procedures |
C09.0.4 | Coordination of pacemaker care or adjustment of nursing interventions |
D. | COGNITIVE / NEUROLOGICAL COMPONENT |
D10.0 | Behavior Care |
D10.0.1 | Evaluation of the scope of activities/actions to monitor the patient's reactions to stimuli |
D10.0.2 | Carrying out activities to monitor the patient's reactions to stimuli |
D10.0.3 | Teach activities to monitor patient reactions to stimuli |
D10.0.4 | Coordination of activities to monitor patient responses to stimuli or adjustment of nursing interventions |
D11.0 | Orientation to reality |
D11.0.1 | Evaluation of the scope of activities/actions to develop the ability to find oneself in the environment |
D11.0.2 | Carrying out activities to develop the ability to find oneself in the environment |
D11.0.3 | Teach activities to develop the ability to find oneself in the environment |
D11.0.4 | Coordination of activities to develop the ability to find oneself in the environment or correction of nursing interventions |
D63.0 | Movement control |
D63.0.1 | Evaluation of the scope of measures/actions to control abnormal patient mobility |
D63.0.2 | Implementation of measures to control abnormal patient mobility |
D63.0.3 | Teach measures to control abnormal patient mobility |
D63.0.4 | Coordination of measures to control abnormal patient mobility or correction of nursing interventions |
D64.0 | Providing assistance to a patient with memory loss |
D64.0.1 | Assessment of the scope of events/actions to restore memory |
D64.0.2 | Carrying out memory restoration activities |
D64.0.3 | Teach memory restoration activities |
D64.0.4 | Coordination of memory restoration activities or correction of nursing interventions |
D78.0 | Providing assistance to a patient with neurological diseases |
D78.0.1 | Assessment of the scope of activities/actions to provide assistance to a patient with neurological problems |
D78.0.2 | Carrying out activities to provide assistance to a patient with problems of the neurological system |
D78.0.3 | To teach measures to provide assistance to a patient with problems of the neurological system |
D78.0.4 | Coordination of activities to provide care to a patient with neurological problems or correction of nursing interventions |
E. | COMPONENT OF PSYCHOLOGICAL ADAPTATION |
E12.2 | Stress management |
E12.2.1 | Assessment of the scope of activities/actions to monitor the patient's physiological responses to stimuli |
E12.2.2 | Carrying out activities to monitor the patient's physiological reactions to stimuli |
E12.2.3 | Teach measures to control physiological reactions to stimuli |
E12.2.4 | Coordination of activities to monitor the patient's physiological reactions to stimuli or correction of nursing interventions |
E12.3 | Crisis psychotherapy/Therapy |
E12.3.1 | Assessment of the scope of activities/actions for the implementation of crisis therapy |
E12.3.2 | Implementation of crisis therapy activities |
E12.3.3 | Train in the activities provided for crisis therapy |
E12.3.4 | Coordination of crisis intervention activities or adjustment of nursing interventions |
E14.0 | Providing assistance to a patient in the terminal stage |
E14.0.1 | Assessment of the scope of activities/actions for patient care during the dying period |
E14.0.2 | Carrying out activities to care for a patient during the dying period |
E14.0.3 | Teach measures for caring for a patient during the period of dying |
E14.0.4 | Coordination of patient care activities during the dying period or adjustment of nursing interventions |
F. | COMPONENT VOLUME OF LIQUID |
F15.0 | Infusion therapy |
F15.0.1 | Assessment of the scope of activities/actions to ensure sufficient fluid intake |
F15.0.2 | Taking steps to consume sufficient amounts of liquid |
F15.0.3 | Teach measures for drinking sufficient amounts of fluids |
F15.0.4 | Coordination of measures to ensure adequate fluid intake or adjustment of nursing interventions |
F15.1 | Hydration Monitoring/Fluid Monitoring – |
F15.1.1 | Assessment of the scope of activities/actions to implement fluid balance control |
F15.1.2 | Carrying out measures to control fluid balance |
F15.1.3 | Teach fluid balance management measures |
F15.1.4 | Coordination of fluid balance management or adjustment of nursing interventions |
F15.3 | Fluid intake |
F15.3.1 | Assessment of the volume of activities/actions to determine the volume of liquid consumed |
F15.3.2 | Carrying out activities to determine the volume of liquid consumed |
F15.3.3 | Teach measures to determine the volume of liquid consumed |
F15.3.4 | Coordination of activities to determine the volume of fluid consumed or correction of nursing interventions |
F15.4 | Fluid removal |
F15.4.1 | Assessment of the volume of activities/actions to determine the volume of fluid removed |
F15.4.2 | Carrying out activities to determine the volume of excreted fluid |
F15.4.3 | Teach measures to determine the volume of excreted fluid |
F15.4.4 | Coordination of activities to determine the volume of fluid excreted or correction of nursing interventions |
F79.0 | Hemodynamic care |
F79.0.1 | Assessment of the scope of activities/actions to regulate the movement of solutions in the blood |
F79.0.2 | Implementation of measures to regulate the movement of solutions in the blood |
F79.0.3 | Teach measures to regulate the movement of solutions in the blood |
F79.0.1 | Coordination of activities to regulate the movement of solutions in the blood or correction of nursing interventions |
F79.2 | Caring for a venous catheter |
F79.2.1 | catheter care |
F79.2.2 | Carrying out activities for the care of a venous catheter |
F79.2.3 | Teach procedures for caring for a venous catheter |
F79.2.4 | catheter care activities or adjustment of nursing interventions |
F79.3 | Arterial Catheter Care |
F79.3.1 | catheter care |
F79.3.2 | Carrying out measures to care for an arterial catheter |
F79.3.3 | Teach procedures for caring for an arterial catheter |
F79.3.4 | catheter care activities or adjustment of nursing interventions |
G. | HEALTH ATTITUDE COMPONENT |
G17.1 | Adult Day Center |
G17.1.1 | Estimation of the scope of activities/activities for the implementation of a day program for adults |
G17.1.2 | Carrying out activities according to the day program for adults |
G17.1.3 | Teach activities according to the adult day program |
G17.1.4 | Coordination of activities according to the adult day program or adjustment of nursing interventions |
G17.3 | Food delivery to your home |
G17.3.1 | Assessment of the scope of activities/actions to provide the patient with nutrition at home |
G17.3.2 | Carrying out activities to provide nutrition to the patient at home |
G17.3.3 | To train in the activities of providing nutrition to the patient at home |
G17.3.4 | Coordination of activities to provide nutrition to the patient at home or adjustment of nursing interventions |
G18.2 | Maintaining water balance |
G18.2.1 | Assessment of the scope of activities/actions to maintain water regime/balance |
G18.2.2 | Implementation of measures to maintain water regime/balance |
G18.2.3 | Teach water regime/balance measures |
G18.2.4 | Coordination of hydration/balance measures or adjustment of nursing interventions |
G18.5 | Observance of safety precautions |
G18.5.1 | Assessing the scope of measures/actions to comply with measures to protect against injury, danger or loss to oneself or others |
G18.5.2 | Carrying out activities to ensure that you or others are protected from injury, danger, or loss |
G18.5.3 | Teach procedures to protect yourself or others from injury, danger, or loss |
G18.5.4 | Coordination of activities to ensure protection from injury, danger or loss to self or others or adjustment of nursing interventions |
G19.1 | Human Rights Act |
G19.1.1 | Assessment of the scope of activities/actions related to the application for sickness benefit |
G19.1.2 | Carrying out activities for writing an application for sickness benefits |
G19.1.3 | Provide training on how to receive sickness benefits |
G19.1.4 | Coordination of sickness benefit activities or adjustment of nursing interventions |
G19.2 | Nursing care coordination |
G19.2.1 | Assessing the scope of activities/actions to summarize the nurse's care plan |
G19.2.2 | Carrying out activities to summarize the nurse's care plan |
G19.2.3 | Teach activities to summarize the nurse's care plan |
G19.2.4 | Coordination of activities to summarize the nurse's care plan or adjustment of nursing interventions |
G21.0 | Highly qualified medical care |
G21.0.1 | Assessment of the scope of activities/actions to support patient functions carried out by the medical team |
G21.0.2 | Carrying out activities to maintain patient functions |
G21.0.3 | Teach activities to maintain patient functions |
G21.0.4 | Coordination of activities to support patient functions or correction of nursing interventions |
G21.1 | Professional care by a trained caregiver |
G21.1.1 | Assessment of the scope of activities/actions for the implementation of care support by a caregiver |
G21.1.2 | Carrying out activities to support care by a caregiver |
G21.1.3 | Train a caregiver in caregiving activities |
G21.1.4 | Coordination of activities for the implementation of nursing care or correction of nursing interventions |
G21.3 | Advanced Practice Nurse Jobs |
G21.3.1 | Assessment of the scope of activities/actions for the implementation of the consultations/instructions provided by an extended practice nurse/practicing nurse |
G21.3.2 | Carrying out activities based on the advice/instructions provided by an extended practice nurse/practicing nurse |
G21.3.3 | Train in activities based on consultations/instructions provided by an extended practice nurse/nurse practitioner |
G21.3.4 | Coordination of activities to provide consultations/instructions by an extended practice nurse/nurse practitioner or adjustment of nursing interventions |
H. | MEDICINAL COMPONENT |
H22.0 | Nursing care for a patient after chemotherapy |
H22.0.1 | Assessment of the scope of activities/actions for performing patient care after chemotherapy |
H22.0.2 | Carrying out patient care activities after chemotherapy |
H22.0.3 | Teach patient care procedures after chemotherapy |
H22.0.4 | Coordination of patient care activities after chemotherapy or adjustment of nursing interventions |
H24.1 | Adverse drug reactions |
H24.1.1 | Evaluation of the scope of activities/actions for monitoring expected reactions to prescribed drugs |
H24.1.2 | Carrying out activities to monitor expected reactions to prescribed drugs |
H24.1.3 | Train in monitoring suspected reactions to prescribed medications |
H24.1.4 | Coordination of activities for monitoring suspected reactions to prescribed drugs |
H24.2 | Preliminary arrangement of drugs in the clinical pharmacy department |
H24.2.1 | Assessment of the scope of activities/actions for the continuous provision of prescribed drugs |
H24.2.2 | Implementation of measures for the continuous provision of prescribed drugs |
H24.2.3 | To train in continuous provision of prescribed medications |
H24.2.4 | Coordination of activities for the continuous provision of medications or adjustment of nursing interventions |
H24.3 | Side effects of the drug |
H24.3.1 | Evaluation of the scope of activities/actions to control adverse reactions to prescribed drugs |
H24.3.2 | Implementation of measures to control adverse reactions to prescribed drugs |
H24.3.3 | To train in measures to control adverse reactions to prescribed drugs. |
H24.3.4 | Coordination of activities to monitor adverse reactions to prescribed drugs or correction of nursing interventions |
H25.0 | Nursing care after radiation therapy |
H25.0.1 | Assessment of the scope of activities/actions for the implementation of care after radiotherapy |
H25.0.2 | Carrying out post-radiation care activities |
H25.0.3 | To train post-radiation care |
H25.0.4 | Coordination of post-radiation care activities or adjustment of nursing interventions |
I. | METABOLISM COMPONENT |
I26.0 | First aid for allergic reaction |
I26.0.1 | Assessment of the scope of measures/actions to relieve allergic reactions/reduce symptoms |
I26.0.2 | Carrying out measures to relieve allergic reactions/reduce symptoms |
I26.0.3 | To teach measures to relieve allergic reactions/reduce symptoms |
I26.0.4 | Coordination of measures to relieve allergic reactions/symptom reduction or correction of nursing interventions |
I27.0 | Caring for a patient with diabetes |
I27.0.1 | Assessment of the scope of activities/actions for the implementation of care for a patient with diabetes |
I27.0.2 | Carrying out activities to care for a patient with diabetes |
I27.0.3 | To train measures to perform care for a patient with diabetes |
I27.0.4 | Coordination of activities for the implementation of care for a patient with diabetes or adjustment of nursing interventions |
I65.0 | Immune system care |
I65.0.1 | Assessment of the scope of measures/actions to implement protection against the disease |
I65.0.2 | Implementation of measures to protect against disease |
I65.0.3 | To teach measures to protect against disease |
I65.0.4 | Coordination of activities to implement protection against the disease |
J. | POWER COMPONENT |
J28.0 | Enteral tube care |
J28.0.1 | Assessment of the scope of activities/actions for care of enteral drainage tube |
J28.0.2 | Carrying out measures for the care of an enteral drainage tube |
J28.0.3 | enteral drainage tube care procedures |
J28.0.4 | enteral drainage tube care or adjustment of nursing interventions |
J28.1 | Insertion of an enteral tube |
J28.1.1 | Assessment of the scope of activities/actions for the installation of an enteral drainage tube |
J28.1.2 | Carrying out measures for the installation of an enteral drainage tube |
J28.1.3 | To teach procedures for inserting an enteral drainage tube |
J28.1.4 | enteral drainage tube placement or adjustment of nursing interventions |
J28.2 | Enteral tube irrigation |
J28.2.1 | Assessment of the scope of activities/actions for flushing the enteral tube |
J28.2.2 | Carrying out measures to flush the enteral tube |
J28.2.3 | To teach procedures for flushing the enteral tube |
J28.2.4 | enteral tube flushing activities or adjustment of nursing interventions |
J29.2 | Feeding techniques |
J29.2.1 | Assessment of the scope of activities/actions for the implementation of special feeding measures |
J29.2.2 | Implementation of measures to implement special feeding measures |
J29.2.3 | To train in the implementation of special feeding measures |
J29.2.4 | Coordination of activities for the implementation of special feeding measures or correction of nursing interventions |
J29.3 | Regular diet |
J29.3.1 | Assessing the volume of activities/actions for food/nutrient intake according to established nutritional standards |
J29.3.2 | Implementation of food/nutrient intake activities in accordance with established nutritional standards |
J29.3.3 | To teach food/nutrient intake activities according to established nutritional standards |
J29.3.4 | Coordination of food/nutrient intake activities according to established nutritional standards or adjustment of nursing interventions |
J29.4 | Special diet |
J29.4.1 | Estimation of the volume of activities/actions for the intake of prescribed specific food/nutrients |
J29.4.2 | Carrying out activities to take prescribed specific food/nutrients |
J29.4.3 | To teach steps to take prescribed specific foods/nutrients |
J29.4.4 | Coordination of activities for the administration of prescribed specific foods/nutrients or adjustment of nursing interventions |
J29.5 | Enteral nutrition |
J29.5.1 | Assessment of the scope of activities/actions for the implementation of nutrition with special mixtures through the gastrointestinal mucosa |
J29.5.2 | Implementation of nutritional measures with special mixtures through the gastrointestinal mucosa |
J29.5.3 | To teach the procedures for administering nutrition with special mixtures through the gastrointestinal mucosa |
J29.5.4 | Coordination of activities for the implementation of nutrition with special mixtures through the gastrointestinal mucosa or correction of nursing interventions |
J29.6 | Parenteral nutrition |
J29.6.1 | Assessment of the scope of activities/actions for the implementation of nutrition by intravenous or subcutaneous infusion bypassing the gastrointestinal tract |
J29.6.2 | Implementation of measures to provide nutrition by intravenous or subcutaneous infusion bypassing the gastrointestinal tract |
J29.6.3 | To teach measures for performing nutrition by intravenous or subcutaneous infusion bypassing the gastrointestinal tract |
J29.6.4 | Coordination of activities for the implementation of nutrition by intravenous or subcutaneous infusion bypassing the gastrointestinal tract or correction of nursing interventions |
TO. | COMPONENT OF REGULATION OF PHYSICAL PROCESSES |
K30.0 | Infection control |
K30.0.1 | Assessment of the scope of measures/actions to prevent the spread of infectious disease |
K30.0.2 | Implementation of measures to prevent the spread of infectious diseases |
K30.0.3 | To teach measures to prevent the spread of infectious diseases |
K30.0.4 | Coordination of activities to prevent the spread of infectious diseases or correction of nursing interventions |
K30.1 | Prevention of hospital-acquired infections – |
K30.1.1 | Assessment of the scope of measures/actions to prevent the spread of infections and infectious diseases |
K30.1.2 | Implementation of measures to prevent the spread of infections and infectious diseases |
K30.1.3 | To teach measures to prevent the spread of infections and infectious diseases |
K30.1.4 | Coordination of activities to prevent the spread of infections and infectious diseases or correction of nursing interventions |
K31.1 | Collecting information about the patient |
K31.1.1 | Assessment of the scope of activities/actions to obtain information about past illnesses and health status |
K31.1.2 | Carrying out activities to obtain information about past illnesses and health status |
K31.1.3 | To teach activities according to the information received about past illnesses and health status |
K31.1.4 | Coordination of activities based on information received about past illnesses and health status or correction of nursing interventions |
K31.3 | Medical examination |
K31.3.1 | physical examination activities/actions to assess the somatic condition |
K31.3.2 | Performing physical examination activities to assess the somatic condition |
K31.3.3 | To teach the procedures for performing a physical examination to assess the somatic condition |
K31.3.4 | Coordination of activities for performing physical examination to assess somatic status or correction of nursing interventions |
K32.0 | Histological examination |
K32.0.1 | Estimation of the scope of activities/actions for collecting/examining a body sample |
K32.0.2 | Carrying out activities for collecting/examining a body sample |
K32.0.3 | To train in body sample collection/examination procedures |
K32.0.4 | Coordination of body sample collection/examination activities or adjustment of nursing interventions |
L. | COMPONENT OF THE RESPIRATORY SYSTEM |
L35.0 | Oxygen therapy |
L35.0.1 | Assessment of the scope of activities/actions for treatment with oxygen |
L35.0.2 | Carrying out treatment activities using oxygen |
L35.0.3 | To teach treatment measures using oxygen |
L35.0.4 | Coordination of activities for the implementation of treatment using oxygen or correction of nursing interventions |
L36.0 | Caring for a patient with lung disease |
L36.0.1 | Assessment of the scope of activities/actions for the implementation of pulmonary hygiene |
L36.0.2 | Carrying out activities to maintain lung hygiene |
L36.0.3 | To teach measures to maintain lung hygiene |
L36.0.4 | Coordination of activities to implement pulmonary hygiene maintenance or correction of nursing interventions |
L36.1 | Breathing exercises |
L36.1.1 | Assessment of the volume of measures/actions for therapy under respiratory or pulmonary load |
L36.1.2 | Carrying out measures to implement therapy under respiratory or pulmonary load |
L36.1.3 | To teach therapeutic measures for respiratory or pulmonary stress |
L36.1.4 | Coordination of activities to implement therapy under respiratory or pulmonary load or correction of nursing interventions |
L36.2 | Physiotherapy of the chest organs |
L36.2.1 | Assessment of the scope of measures/actions to ensure postural drainage of the lungs |
L36.2.2 | Implementation of measures to ensure postural drainage of the lungs |
L36.2.3 | To teach activities for performing postural drainage of the lungs |
L36.2.4 | Coordination of postural pulmonary drainage activities or correction of nursing interventions |
L36.3 | Inhalation therapy |
L36.3.1 | Assessment of the volume of activities/actions for respiratory procedures |
L36.3.2 | Carrying out activities on breathing procedures |
L36.3.3 | To teach the procedures for performing breathing procedures |
L36.3.4 | Coordination of activities for the implementation of respiratory procedures or correction of nursing interventions |
L36.4 | Care of the respiratory system |
L36.4.1 | Assessment of the scope of measures/actions for control and monitoring of the use of artificial ventilation |
L36.4.2 | Implementation of measures to ensure the use of artificial ventilation |
L36.4.3 | To teach measures for the use of artificial ventilation |
L36.4.4 | Coordination of activities for the implementation of the use of artificial ventilation or correction of nursing interventions |
L37.0 | Tracheostomy care technique |
L37.0.1 | tracheostomy care |
L37.0.2 | tracheostomy care activities |
L37.0.3 | tracheostomy care |
L37.0.4 | tracheostomy care activities or adjustment of nursing interventions |
M. | RELATIONSHIP COMPONENT |
M39.4 | Analysis of sexual behavior |
M39.4.1 | Evaluation of the scope of activities/actions to change and/or modify human sexual response |
M39.4.2 | Carrying out activities to change and/or modify a person's sexual response |
M39.4.3 | To teach interventions to change and/or modify human sexual response |
M39.4.4 | Coordination of activities to implement changes and/or modifications to human sexual response |
N. | SECURITY COMPONENT |
N40.0 | Nursing interventions for patients with drug use/substance abuse |
N40.0.1 | avoid harm |
N40.0.2 | Implementation of measures to minimize or avoid harm |
N40.0.3 | avoid harm |
N40.0.4 | Coordination of activities to implement harm minimization or avoidance or adjustment of nursing interventions |
N40.2 | Nursing interventions for patients with alcohol use |
N40.2.1 | Assessment of the scope of measures/actions to prevent and minimize the consumption of alcoholic beverages. |
N40.2.2 | Implementation of measures to prevent and minimize the consumption of alcoholic beverages. |
N40.2.3 | To teach measures to prevent and minimize the consumption of alcoholic beverages. |
N40.2.4 | Coordination of activities to implement prevention, minimization of alcohol consumption or correction of nursing interventions |
N40.3 | Nursing Intervention for Drug Abuse |
N40.3.1 | Assessing the scope of measures/actions to avoid or minimize any addictive drug. |
N40.3.2 | Taking steps to avoid and minimize any addictive drug. |
N40.3.3 | avoidance and minimization measures for any addictive drug. |
N40.3.4 | Coordination of activities to implement avoidance , minimization of any addictive drug or adjustment of nursing interventions |
N41.0 | Nursing intervention in emergency care |
N41.0.1 | Assessment of the scope of activities/actions to provide emergency care. |
N41.0.2 | Carrying out measures to provide emergency assistance. |
N41 0.3 | To teach emergency care procedures |
N41.0.4 | Coordination of emergency care activities or adjustment of nursing interventions |
P. | SELF-ASSESSMENT COMPONENT |
P45.0 | Mental Health Care |
P45.0.1 | Evaluation of the scope of activities/actions to improve the emotional state |
P45.0.2 | Carrying out activities to improve emotional state |
P45.0.3 | To teach activities to improve emotional state |
P45.0.4 | Coordination of activities to improve emotional state or correction of nursing interventions |
P45.1 | History of mental health |
P45.1.1 | Assessing the scope of activities/actions to obtain information about past or present emotional well-being/health. |
P45.1.2 | Carrying out activities to obtain information about past or present emotional well-being/health. |
P45.1.3 | To teach activities based on information received about past or present emotional well-being/health. |
P45.1.4 | Coordination of activities based on information received about past or present emotional well-being/health or adjustment of nursing interventions |
P45.2 | Strengthening mental health |
P45.2.1 | Evaluation of the scope of activities/actions to improve emotional well-being/health |
P45.2.2 | Implementing activities to improve emotional well-being/health |
P45.2.3 | To teach activities to improve emotional well-being/health |
P45.2.4 | Coordination of activities to improve emotional well-being/health or adjustment of nursing interventions |
P45.3 | Mental health screening |
P45.3.1 | Evaluation of the scope of activities/actions for the assessment of emotional well-being/health |
P45.3.2 | Conducting emotional well-being/health screening activities |
P45.3.3 | To teach activities according to the emotional well-being/health survey |
P45.3.4 | Coordination of activities to perform emotional well-being/health assessment or adjustment of nursing interventions |
Q. | SENSOR COMPONENT |
Q47.0 | Pain management |
Q47.0.1 | Assessing the scope of activities/actions to support the response to injury or damage |
Q47.0.2 | Carrying out activities to implement a response to injury or damage |
Q47.0.3 | To teach caregiving activities to respond to injury or damage |
Q47.0.4 | Coordination of activities to implement a response to trauma or injury or adjustment of nursing interventions |
Q47.1 | Acute pain management |
Q47.1.1 | Assessment of the scope of measures/actions for the implementation of acute pain management |
Q47.1.2 | Implementation of acute pain management measures |
Q47.1.3 | To teach nursing interventions to manage acute pain |
Q47.1.4 | Coordination of activities to implement acute pain management or adjustment of nursing interventions |
Q47.2 | Chronic Pain Management |
Q47.2.1 | Evaluation of the scope of activities/actions for the implementation of chronic pain management |
Q47.2.2 | Implementation of chronic pain management activities |
Q47.2.3 | To teach chronic pain management interventions |
Q47.2.4 | Coordination of activities to implement chronic pain management or adjustment of nursing interventions |
Q48.0 | Patient care to ensure comfort |
Q48.0.1 | Assessing the scope of activities/actions to promote or improve well-being |
Q48.0.2 | Carrying out activities to promote or improve well-being |
Q48.0.3 | To teach activities to promote or improve well-being |
Q48.0.4 | Coordination of activities to promote or improve well-being or adjustment of nursing interventions |
Q49.0 | Ear care |
Q49.0.1 | Estimation of the volume of ear care activities/actions |
Q49.0.2 | Carrying out ear care activities |
Q49.0.3 | To teach ear care procedures |
Q49.0.4 | Coordination of ear care activities or adjustment of nursing interventions |
Q49.1 | Caring for your hearing aid |
Q49.1.1 | Assessing the scope of activities/actions for hearing aid care |
Q49.1.2 | Carrying out activities to care for the hearing aid |
Q49.1.3 | To teach hearing aid care procedures |
Q49.1.4 | Coordination of hearing care activities or adjustment of nursing interventions |
Q49.2 | Earwax removal |
Q49.2.1 | Estimation of the scope of measures/actions for ear wax removal |
Q49.2.2 | Carrying out measures to remove earwax |
Q49.2.3 | To teach ear wax removal procedures |
Q49.2.4 | Coordination of ear wax removal procedures or adjustment of nursing interventions |
Q50.0 | Eye care |
Q50.0.1 | Estimation of the scope of eye care activities/actions |
Q50.0.2 | Carrying out eye care activities |
Q50.0.3 | To teach eye care activities |
Q50.0.4 | Coordination of eye care activities or adjustment of nursing interventions |
Q50.1 | Eye care for cataracts |
Q50.1.1 | Assessment of the scope of activities/actions for eye care in cataracts |
Q50.1.2 | Carrying out eye care activities for cataracts |
Q50.1.3 | To teach eye care measures for cataracts |
Q50.1.4 | Coordination of cataract eye care activities or adjustment of nursing interventions |
Q50.2 | Care for vision problems |
Q50.2.1 | Assessment of the scope of activities/actions for vision care |
Q50.2.2 | Carrying out activities to provide vision care |
Q50.2.3 | To teach vision care activities |
Q50.2.4 | Coordination of vision care activities or adjustment of nursing interventions |
R. | SKIN INTEGRITY COMPONENT |
R51.0 | Care for bedsores |
R51.0.1 | Assessment of the scope of measures/actions for the prevention, detection and treatment of pressure ulcers |
R51.0.2 | Implementation of measures to prevent, detect and treat pressure ulcers |
R51.0.3 | To train in nursing interventions for the prevention, detection and treatment of pressure ulcers |
R51.0.4 | Coordination of activities to implement prevention, detection and treatment of pressure ulcers or correction of nursing interventions |
R51.1 | Care for stage 1 bedsores |
R51.1.1 | Assessment of the scope of measures/actions for the prevention, detection and treatment of stage 1 pressure ulcers |
R51.1.2 | Implementation of measures to prevent, detect and treat stage 1 pressure ulcers |
R51.1.3 | To teach nursing interventions to prevent, detect and treat stage 1 pressure ulcers |
R51.1.4 | Coordination of activities for the implementation of prevention, detection and treatment of stage 1 pressure ulcers or correction of nursing interventions |
R51.2 | Care for Stage 2 Bedsores |
R51.2.1 | Assessment of the scope of measures/actions for the prevention, detection and treatment of stage 2 pressure ulcers |
R51.2.2 | Implementation of measures to prevent, detect and treat stage 2 pressure ulcers |
R51.1.3 | To teach nursing interventions to prevent, detect and treat stage 2 pressure ulcers |
R51.2.4 | Coordination of activities for the implementation of prevention, detection and treatment of stage 2 pressure ulcers or correction of nursing interventions |
R51.3 | Care for Stage 3 Bedsores |
R51.3.1 | Assessment of the scope of activities/actions for the prevention, detection and treatment of stage 3 pressure ulcers |
R51.3.2 | Implementation of measures to prevent, detect and treat stage 3 pressure ulcers |
R51.1.3 | To teach nursing measures for the prevention, detection and treatment of stage 3 pressure ulcers |
R51.3.4 | Coordination of activities for the implementation of prevention, detection and treatment of stage 3 pressure ulcers or correction of nursing interventions |
R51.4 | Care for Stage 4 Bedsores |
R51.4.1 | Assessment of the scope of measures/actions for the prevention, detection and treatment of stage 4 pressure ulcers |
R51.4.2 | Implementation of measures to prevent, detect and treat stage 4 pressure ulcers |
R51.1.3 | To teach nursing interventions to prevent, detect and treat stage 4 pressure ulcers |
R51.4.4 | Coordination of activities for the implementation of prevention, detection and treatment of stage 4 pressure ulcers or correction of nursing interventions |
R53.0 | Oral care |
R53.0.1 | Assessment of the scope of activities/actions for oral care |
R53.0.2 | Carrying out oral care activities |
R53.0.3 | To teach oral care activities |
R53.0.4 | Coordination of oral care activities or adjustment of nursing interventions |
R53.1 | Caring for dentures |
R53.1.1 | Assessment of the scope of activities/actions for the care of dentures |
R53.1.2 | Carrying out activities for the care of dentures |
R53.1.3 | To teach denture care procedures |
R53.1.4 | Coordination of activities for the implementation of dental care or correction of nursing interventions |
R54.0 | Skin care |
R54.0.1 | Assessment of the scope of activities/actions to maintain the condition of the skin. |
R54.0.2 | Carrying out skin care activities |
R54.0.3 | To teach skin care procedures |
R54.0.4 | Coordination of activities to implement skin/skin maintenance or correction of nursing interventions |
R54.1 | Nursing interventions for risk of skin destruction |
R54.1.1 | Assessment of the scope of activities/actions in case of destruction of the skin |
R54.1.2 | Carrying out measures to eliminate destruction of the skin |
R54.1.3 | To teach care measures for skin destruction |
R54.1.4 | Coordination of measures in case of skin destruction or correction of nursing interventions |
R55.0 | Caring for damaged exposed skin areas |
R55.0.1 | Assessment of the scope of measures/actions for the care of damaged exposed skin areas |
R55.0.2 | Carrying out care measures for damaged exposed skin areas |
R55.0.3 | To teach care measures for damaged exposed skin areas |
R55.0.4 | Coordination of activities to provide care for damaged exposed skin areas or correction of nursing interventions |
R55.1 | Drainage care |
R55.1.1 | Assessment of the scope of activities/actions for the functioning of drainage tubes |
R55.1.2 | Carrying out activities for the functioning of drainage tubes |
R55.1.3 | To teach the procedures for performing drainage tubes |
R55.1.4 | Coordination of activities to ensure the functioning of drainage tubes or correction of nursing interventions |
R55.2 | Bandaging |
R55.2.1 | Estimation of the scope of activities/actions for removal and replacement of a new dressing |
R55.2.2 | Carrying out activities for removing and replacing a new dressing |
R55.2.3 | To teach procedures for removing and replacing a new dressing |
R55.2.4 | Coordination of activities to perform removal and replacement of a new dressing or correction of nursing interventions |
R55.3 | Caring for a surgical wound |
R55.3.1 | Assessment of the scope of activities/actions for the treatment of a surgical wound |
R55.3.2 | Carrying out measures for the treatment of a surgical wound |
R55.3.3 | To teach surgical wound care procedures |
R55.3.4 | Coordination of activities for the treatment of a surgical wound or correction of nursing interventions |
R81.0 | Caring for a patient with burns |
R81.0.1 | Assessment of the scope of measures/actions for healing burned areas of the body. |
R81.0.2 | Carrying out measures to heal burned areas of the body. |
R81.0.3 | To teach procedures for caring for burned areas of the body. |
R81.0.4 | Coordination of activities for the implementation of care for burned areas of the body or correction of nursing interventions |
S. | TISSUE PERFUSION COMPONENT |
S56.0 | Foot care |
S56.0.1 | Assessment of the scope of activities/actions to eliminate leg problems |
S56.0.2 | Carrying out foot care activities |
S56.0.3 | To teach foot care activities |
S56.0.4 | Coordination of foot care activities or adjustment of nursing interventions |
S57.0 | Perineal care |
S57.0.1 | Assessment of the scope of activities/actions to eliminate problems in the perineum |
S57.0.2 | Carrying out perineal care activities |
S57.0.3 | To teach perineal care procedures |
S57.0.4 | Coordination of foot care activities or adjustment of nursing interventions |
S69.0 | Care for excess fluid in the tissue |
S69.0.1 | Assessment of the scope of measures/actions to manage excess fluid in the tissue |
S69.0.2 | Implementation of measures to manage excess fluid in the tissue |
S69.0.3 | To teach measures to manage excess fluid in tissue |
S69.0.4 | Coordination of activities to implement management of excess fluid in tissue or correction of nursing interventions |
S70.0 | Care to maintain normal blood circulation |
S70.0.1 | Assessment of the scope of measures/actions in case of disturbance of normal blood circulation |
S70.0.2 | Carrying out measures in case of disturbance of normal blood circulation |
S70.0.3 | To teach measures to deal with circulatory disorders |
S70.0.4 | Coordination of measures to maintain normal blood circulation or correction of nursing interventions |
S82.0 | Care for problems with the vascular system |
S82.0.1 | Assessment of the scope of activities/actions for the management of vascular system problems |
S82.0.2 | Carrying out care activities for problems of the vascular system |
S82.0.3 | To teach care measures for vascular problems |
S82.0.4 | Coordination of activities for the implementation of care for problems of the vascular system or correction of nursing interventions |
T. | COMPONENT OF THE UROGENITAL SYSTEM |
T58.0 | Care for urinary dysfunction |
T58.0.1 | Assessment of the scope of measures/actions in case of urinary dysfunction |
T58.0.2 | Carrying out measures in case of urination disorders |
T58.0.3 | To teach measures for urinary dysfunction |
T58.0.4 | Coordination of activities in case of urinary dysfunction or correction of nursing interventions |
T58.1 | Instillation of the bladder |
T58.1.1 | Assessment of the volume of activities/actions for infusing the solution into the bladder through a catheter |
T58.1.2 | Carrying out activities to infuse fluid into the bladder through a catheter |
T58.1.3 | To teach the procedure of infusing the solution into the bladder through a catheter |
T58.1.4 | Coordination of activities for the implementation of infusion of solution into the bladder through a catheter or correction of nursing interventions |
T58.2 | Caring for urinary drainage |
T58.2.1 | Evaluation of the scope of activities/actions for training in urinary drainage care |
T58.2.2 | Implementation of activities to teach urinary drainage care |
T58.2.3 | To teach urinary drainage care procedures |
T58.2.4 | Coordination of activities for the implementation of training in urinary drainage care or correction of nursing interventions |
T59.0 | Care while on dialysis |
T59.0.1 | Assessment of the scope of activities/actions to remove waste products and excess fluid from the body |
T59.0.2 | Carrying out activities to remove waste products and excess fluid from the body |
T59.0.3 | To teach measures to remove waste products and excess fluid from the body |
T59.0.4 | Coordination of activities to remove waste products and excess fluid from the body or correction of nursing interventions |
T59.1 | Care while on hemodialysis |
T59.1.1 | Assessment of the scope of activities/actions for mechanical removal of waste products from the blood |
T59.1.2 | Carrying out activities for the mechanical removal of waste products from the blood |
T59.1.3 | To teach the procedures for mechanical removal of waste products from the blood |
T59.1.4 | Coordination of activities to perform mechanical removal of waste products from the blood or correction of nursing interventions |
T59.2 | Care while on peritoneal dialysis |
T59.2.1 | Assessment of the scope of activities/actions for osmotic removal of waste products from the blood |
T59.2.2 | Carrying out measures of osmotic removal of waste products from the blood |
T59.2.3 | To teach the measures of osmotic removal of waste products from the blood |
T59.2.4 | Coordination of activities to perform osmotic removal of waste products from the blood or correction of nursing interventions |
T60.0 | Caring for a urinary catheter |
T60.0.1 | Evaluation of the scope of measures/actions for managing urinary catheter use. |
T60.0.2 | Carrying out activities for the use of a urinary catheter |
T60.0.3 | To teach urinary catheter care procedures |
T60.0.4 | Coordination of activities for the implementation of urinary catheter use or adjustment of nursing interventions |
T60.1 | Placing a urinary catheter |
T60.1.1 | Assessment of the scope of activities/actions for the installation of a urinary catheter in the bladder. |
T60.1.2 | Carrying out measures to place a urinary catheter in the bladder. |
T60.1.3 | To teach procedures for caring for a urinary catheter in the bladder. |
T60.1.4 | Coordination of activities for the placement of a urinary catheter in the bladder or correction of nursing interventions |
T60.2 | Irrigation of urinary catheter |
T60.2.1 | Assessment of the scope of activities/actions for flushing a urinary catheter. |
T60.2.2 | Carrying out procedures for flushing a urinary catheter. |
T60.2.3 | To teach procedures for flushing a urinary catheter. |
T60.2.4 | Coordination of urinary catheter flushing activities or adjustment of nursing interventions |
T72.0 | Care for inability to hold urine and/or involuntary loss of urine |
T72.0.1 | Evaluation of the scope of measures/actions to manage inability to hold urine and/or involuntary loss of urine. |
T72.0.2 | Implementation of measures to manage the inability to retain and/or involuntary release of urine |
T72.0.3 | To teach measures to manage inability to hold urine and/or involuntary loss of urine. |
T72.0.4 | Coordination of activities to implement management of inability to retain urine and/or involuntary loss of urine or correction of nursing interventions |
T73.0 | Care for kidney problems |
T73.0.1 | Assessment of the scope of measures/actions for the management of kidney problems |
T73.0.2 | Implementation of measures to manage kidney problems |
T73.0.3 | To teach kidney care measures |
T73.0.4 | Coordination of renal care activities or adjustment of nursing interventions |
T83.0 | Caring for a bladder stoma (cystostomy) |
T83.0.1 | Assessment of the scope of activities/actions for the functioning of an artificial opening for urine removal |
T83.0.2 | Carrying out activities for the functioning of an artificial opening for the removal of urine |
T83.0.3 | To teach procedures for caring for urine removal artificial opening |
T83.0.4 | Coordination of activities for the implementation of care for an artificial opening for the urine removal or correction of nursing interventions |
T83.1 | Irrigation of the bladder stoma (cystostomy) |
T83.1.1 | Assessment of the scope of activities/actions for flushing the artificial opening for urine removal |
T83.1.2 | Carrying out activities to flush the artificial opening for urine removal |
T83.1.3 | Teach the procedures for flushing the artificial opening to remove urine |
T83.1.4 | Coordination of activities for performing irrigation of the artificial opening for urine removal or correction of nursing interventions |
U. | REPRODUCTIVE HEALTH COMPONENT |
U74.1 | Care for patients of childbearing age |
U74.1.1 | Evaluation of the scope of activities/actions to increase the possibility of conceiving offspring/a child. |
U74.1.2 | Carrying out activities to increase the possibility of conceiving offspring/a child. |
U74.1.3 | To teach measures to increase the possibility of conceiving offspring/a child. |
U74.1.4 | Coordination of activities to increase the possibility of conception of offspring/child or correction of nursing interventions |
U74.2 | Nursing interventions to promote conception of offspring/child in patients with infertility |
U74.2.1 | Assessment of the scope of activities/actions for the treatment of infertility |
U74.2.2 | Carrying out infertility treatment activities |
U74.2.3 | To teach about infertility treatment measures |
U74.2.4 | Coordination of activities for the implementation of infertility treatment or correction of nursing interventions |
U74.3 | Contraception |
U74.3.1 | Assessment of the scope of measures/actions to prevent conception of offspring/child. |
U74.3.2 | Carrying out measures to prevent conception of offspring/child. |
U74.3.3 | To teach measures to prevent conception of offspring/child. |
U74.3.4 | Coordination of activities to implement the prevention of conception of offspring/child or correction of nursing interventions |
U75.3 | Care during childbirth |
U75.3.1 | Assessment of the volume of activities/actions to support at the time of the birth of offspring/child |
U75.3.2 | Carrying out activities at the time of extraction of offspring/child |
U75.3.3 | To teach care measures at the time of birth of offspring/child |
U75.3.4 | Coordination of activities to implement support at the time of birth of offspring/child or correction of nursing interventions |
| Appendix 5 to the Rules for the provision |
|
| of medical care to persons | |
| with chronic diseases, periodicity and duration |
|
| of observation, mandatory minimum and |
|
| frequency of diagnostic tests |
Frequency of dynamic observation (examination by a medical technician and a primary care physician), laboratory and instrumental tests, examinations by specialized medical practitioners based on patient segmentation within the framework of the PHC
№ | Population category (segmentation zone) based on a set of clinical and behavioral indicators | Frequency of examinations - scheduled appointments | Minimum laboratory diagnostic tests | |||
examination of CSF (cerebrospinal fluid) | examination by a primary care physician | examination by specialized medical practitioners | tests | frequency | ||
1 | Arterial hypertension | |||||
1.1 | Optimal (green zone) | |||||
High normal blood pressure | 4 times a year | Once a year | - |
Determination of microalbum in in urine | Once a year | |
Electrocardiography | Once a year | |||||
1.2 | Suboptimal (yellow zone) | |||||
1-3 degree of arterial pressure when target values are not reached | Once every 3 months | Once in 6 months | By decision of the MDC |
Determination of microalbumin |
Once a year, | |
Electrocardiography |
Once a year, | |||||
hour blood pressure monitoring |
Once a year, | |||||
Echocardiography |
Once a year, | |||||
1.3 | Bad (red zone) | |||||
1-3 degree of arterial pressure with persistent risk factors (if target values are not reached) | Once a month | Once a month | By decision of the MDC |
Determination of microalbumin in urine |
Twice a year, | |
Electrocardiography |
Twice a year, | |||||
hour blood pressure monitoring |
Once a year, | |||||
Echocardiography |
Once a year, | |||||
2 | Type 2 diabetes | |||||
2.1 | Optimal (green zone) | |||||
Glycated hemoglobin <or = 7.0 | Once every 6 months. | Once every 6 months. | - |
Biochemical blood tests: determination of glycated hemoglobin in the blood, blood creatinine with calculation of the glomerular filtration rate (GFR), | Once a year | |
Ophthalmoscopy with wide pupil | Once a year | |||||
2.2 | Suboptimal (yellow zone) | Once a year | ||||
Glycated hemoglobin from 7.1-9.0 | Once every 3 months | Once in 3 months | By decision of the MDC | Biochemical blood tests: determination of glycated hemoglobin in the blood, | By decision of the MDC | |
Determination of blood creatinine with calculation of glomerular filtration rate (GFR), | ||||||
Low density lipoproteins | ||||||
Ophthalmoscopy with wide pupil | By decision of the MDC | |||||
Determination of microalbumin in urine | ||||||
2.3 | Bad (red zone) | |||||
Glycated hemoglobin> 9.1 | Once a month | Once a month | By decision of the MDC | Biochemical blood tests: determination of glycated hemoglobin in the blood, blood creatinine with calculation of glomerular filtration rate (GFR), lipid spectrum | By decision of the MDC | |
Determination of | By decision of the MDC | |||||
Ophthalmoscopy with wide pupil | By decision of the MDC | |||||
3 | Chronic heart failure | |||||
3.1 | Optimal (green zone) | |||||
New York Heart Association Class I | Once every 3 months | Once every 3 months | Once a year a cardiologist |
Determination of blood creatinine with calculation of SCF creatinine | Once a year | |
Electrocardiogram | Once a year | |||||
Echocardiography | Once a year | |||||
Determination of microalbumin in urine | Once a year | |||||
Sodium | By decision of the MDC | |||||
Potassium | By decision of the MDC | |||||
3.2 | Suboptimal (yellow zone) | |||||
New York Heart Association Class II - IV | Once every 3 months | Once in 6 months | By decision of the MDC |
Determination of blood creatinine with calculation of SCF | By decision of the MDC | |
| By decision of the MDC | |||||
Echocardiography | By decision of the MDC | |||||
Determination of microalbumin in urine | By decision of the MDC | |||||
3.3 | Bad (red zone) | |||||
New York Heart Association Class IV | Once a month | Once every 3 months | By decision of the MDC |
Determination of blood creatinine with calculation of SCF | By decision of the MDC | |
Electrocardiogram | By decision of the MDC | |||||
Echocardiography | By decision of the MDC | |||||
Determination of microalbumin in urine | By decision of the MDC | |||||
Segmentation
Population segmentation is the division of the target population within the disease management Program into groups that are sufficiently homogeneous to be feasible.
Note:
Population segmentation is the division of the target population within the disease management Program into groups that are sufficiently homogeneous to enable the creation of a package of the most appropriate health services to meet the anticipated needs of patients.
*Norms for albumin/microalbumin in urine (0 – 30) mg/day.
**Norms for creatinine in urine (5 – 18) mmol/day.
There are 3 zones of population segmentation within the framework of the disease management Program: Red (Bad),
Yellow (Suboptimal), Green (optimal).
There are two types of criteria for population segmentation:
1. Clinical criteria based on relevant clinical guidelines and clinical protocols. These clinical criteria were added to the patient observation cards for specific diseases.
2. Behavioral criteria that measure the patient's level of confidence in managing symptoms and health problems.
The clinical criteria for each disease in the DMP are:
1. Primary arterial hypertension
High normal - BP 130-139 and/or 85-89 (code "0" in the register)
Stage 1 - BP 140-159 and/or 90-99 (code "1" in the register)
Stage 2 - BP 160-179 and/or 100-109 (code "2" in the register)
Stage 3 - BP≥180 and/or ≥110 (code "3" in the register)
2. Type 2 diabetes
Glycated hemoglobin < 7.0
Glycated hemoglobin from 7.0-9.0
Glycated hemoglobin> 9.0
3. Chronic heart failure
Class I (according to the New York Heart Association) - no symptoms.
Class II (according to the New York Heart Association) - symptoms occur with ordinary physical activity.
Class III (according to the New York Heart Association) - symptoms occur with little physical activity.
Class IV (according to the New York Heart Association) - onset of symptoms at rest.
The frequency of examinations is determined individually, taking into account the condition and needs of each patient. It is determined by the doctor in accordance with clinical protocols and recommendations established for a particular disease.
Appendix 1 to the Rules for the organization of provision of medical care to persons with chronic diseases, periodicity and duration of observation, the mandatory minimum and frequency of diagnostic tests “List of diseases subject to dynamic observation in primary health care organizations within the framework of the guaranteed volume of free medical care” shall be set out in a new version in accordance with Appendix 1 to this List;
Appendix 2 to the Rules for the organization of provision of medical care to persons with chronic diseases, periodicity and duration of observation, mandatory minimum and frequency of diagnostic tests "List of socially significant diseases subject to dynamic observation by specialized medical practitioners at the level of consultative and diagnostic care within the framework of the guaranteed volume of free medical care" shall be set out in a new version in accordance with Appendix 2 to this List;
Appendix 3 to the Rules for the organization of provision of medical care to persons with chronic diseases, periodicity and duration of observation, mandatory minimum and frequency of diagnostic studies "List of chronic diseases subject to observation by specialized medical practitioners at the level of consultative and diagnostic care within the framework of the guaranteed volume of free medical care and (or) in the system of compulsory social health insurance" shall be set out in a new version in accordance with Appendix 3 to this List;
The rules for organizing the provision of medical care to individuals with chronic diseases, periodicity and duration of observation, mandatory minimum and frequency of diagnostic tests shall be supplemented with Appendix 4 “Table 1. Classification of nursing diagnoses and Table 2. Classification of nursing interventions” in accordance with Appendix 4 to this List;
The rules for organizing the provision of medical care to individuals with chronic diseases, periodicity and duration of observation, mandatory minimum and frequency of diagnostic tests shall be supplemented with Appendix 5 “Frequency of dynamic observation (examination of CSF and by a primary care physician), laboratory and instrumental tests, examinations by specialized medical practitioners based on patient segmentation within the framework of the DMP” in accordance with Appendix 5 to this List.
| Appendix 2 to the order |
List of some orders of the Ministry of Healthcare of the Republic of Kazakhstan that have become invalid
1) order of the Minister of Health of the Republic of Kazakhstan dated March 30, 2019 № RK MH-16 "On approval of the Rules for dynamic observation of patients with chronic diseases" (registered in the Register of State Registration of Normative Legal Acts on April 8, 2019 under № 18474, published on April 16, 2019 in the Reference Control Bank of regulatory legal acts of the Republic of Kazakhstan in electronic form);
2) order of the Minister of Health of the Republic of Kazakhstan dated October 17, 2019 № RK MH-136 "On approval of the list of chronic diseases, in which dynamic observation of patients is carried out, the list of socially significant diseases for which medical and social assistance is provided, the list of diagnostic services, including number of laboratory diagnostics, a list of infectious diseases and diseases that pose a danger to others, a list of diseases that are not subject to dynamic monitoring within the guaranteed volume of free medical care, a list of certain categories of the population subject to emergency and planned dental care, a list of diseases (conditions) subject to medical rehabilitation and restorative treatment in the direction of a specialist in primary health care or a medical organization "(registered in the Register of State Registration of Normative Legal Acts on October 18, 2019 under № 19484,published on October 18, 2019 year in the Reference Control Bank of regulatory legal acts of the Republic of Kazakhstan in electronic form).
