In the hospital found errors in medical records and journals

On November 6, Roszdravnadzor announced a warning to the Polesie Central District Hospital due to shortcomings in the preparation of medical documentation. The comments relate to an outpatient card of a patient who died in May 2026 and a log of admissions to the emergency room.

In particular, the copy of the outpatient card did not contain information about the examination of the patient by a physician on May 14. The documents did not indicate complaints, anamnesis, the results of an objective examination and the established diagnosis. At the same time, there was a record in the admissions log that a man with acute pancreatitis was examined at a temperature of 39.8 degrees, after which he was sent to the Chernyakhov Central District Hospital for further examination and treatment.

In addition, the inspectors found that the patient admission log did not contain a number of mandatory graphs. There were no fields for information about the patient's documents, citizenship, registration, MHI policy, SNILS, the circumstances of injuries and poisonings, the results of examinations, referral to the department and the outcome of hospitalization. The diagnosis also did not have an ICD code.

The copy of the ambulatory card did not contain a postmortem epicritis, although the title page contained a mark of the patient's death on May 16, 2026. The document itself, according to the supervisory authority, partially did not correspond to the established form.

The territorial body of Roszdravnadzor in the Kaliningrad region suggested that the hospital take measures to ensure that medical documentation is kept in accordance with mandatory requirements.