The personal outpatient record, also known as the health record, is an important document that contains the entire medical history, diagnoses, treatments and health care recommendations of each individual patient. Filling it out is a must when visiting a doctor or medical professional, especially when it comes to pregnancy or caring for a child. In this blog, we will look at the steps in filling out the outpatient card, emphasizing the rules and regulatory requirements in Bulgaria.
Basic elements of the ambulatory card
Completing an outpatient card involves several key steps that ensure completeness and accuracy of information:
- personal data – includes the patient's full name, social security number, address of permanent residence, and contact details;
- medical history – documents previous illnesses, surgeries, allergies, and current condition;
- visits to doctors - describes dates of visits, diagnoses, treatment prescriptions and recommendations;
- certification and signature – each entry must be certified with a signature by the relevant specialist.
The importance of regularly updating the outpatient card
It must be regularly updated and reflect any change in the patient's health status:
- with any new disease – it is important to add the new information for better diagnosis and treatment in the future;
- after each procedure – updating data after each procedure ensures that all specialists have the most up-to-date information on the patient's condition.
Recommendations when filling out an outpatient card
To make sure that the information is always accurate and up-to-date, you can use a template and follow a few basic guidelines:
- keeping regular records - it is recommended to actively participate in the process and update your card;
- communication with medical personnel - communicate openly with your doctors and provide complete information about your health;
- save copies - keep copies of your documents in order to have access to them when necessary or in emergency situations;
- for sick leave - make sure that all data related to sick leaves are entered correctly. This includes dates of issue, diagnosis and recommended recovery period.
This is a frequently asked question. In most cases, they can be found in the nearest bookstore or are issued directly by medical institutions.
The outpatient record is an important health management document that ensures continuous, consistent and comprehensive care. Maintaining it helps healthcare professionals make informed decisions based on a complete clinical picture, ultimately leading to better health outcomes.