Medical Documentation Accounting and Operational Statistical

Medical registration and operational statistical documentation (M.d.u.-o.st.) are primary accounting documents that reflect individual elements of the daily work of medical institutions, help organize this work and are used to compile reporting medical documentation.

M.d.u.-o.st. includes various accounting and reporting forms filled out by medical personnel. These include:

1. Disease history
2. Certificate of incapacity for work
3. Referral for hospitalization, consultation, examination
4. Emergency notification of infectious disease
5. Statistical map of those leaving the hospital
6. and etc.

These documents contain information about patients, diagnoses, volume and nature of medical care provided. They are filled out in the process of serving patients and are used for current accounting of work and preparation of periodic reports of medical institutions.

Thus, M.d.u.-o.st. provides continuous accounting of the activities of medical institutions and reflects the main statistical indicators of their work necessary for analysis and planning.

**Medical documentation** is a set (system) of records made in the prescribed manner, indicating the process, results and consequences of medical activities necessary for its (process) documentation. **Accounting - operational** - reflects specific points in time. All of them constitute a single documentation - **statistical,** as a methodological device. The following elements of static data grouping are distinguished:

* **Primary accounting** – makes it possible to reflect all patients participating in the treatment process in all institutions. With the development of the media, it includes not only statistics of medical work, but also demographic work, indicating the sources of its implementation. * The accounting and operational type contains almost all the information about the volume of services provided by the doctor, and is then used to calculate the financing structure and wages for medical care provided.

In addition, accounting and operational documentation is the main element in analyzing the work of outpatient clinics. Without such statistics, it is impossible to judge how “aligned” dispensary observation is. The accounting and operational view should be of three types: by days of visit, by sick days and by visits. Thanks to the availability of this type of reporting, all diagnostic studies performed on an outpatient basis, in a day hospital, or inpatient substitution methods, are performed by specialists from the clinic at the patient’s place of residence. The main condition that characterizes any type of medical care provided in a health care facility is the quality of the care provided. Quality helps identify gaps and unused reserves in a doctor’s work. In medical statistics, when developing individual quality issues, two groups are distinguished: - random single errors - systematic

The methodological features of static processing include: - the secondary nature of the process of statistical and economic analysis - the use of a large number of tables - limiting the number of digital values ​​that make up the reporting.