FEATURES OF WRITING OF PEDIATRIC MEDICAL CASES HISTORIES AT THE DEPARTMENT OF CHILDREN'S DISEASES WITH PEDIATRIC SURGERY IN MODERN CONDITIONS

Abstract

Abstract. The medical case history (hospitalized patient medical record) is an important medical and legal document that is filled out upon hospitalization for each hospitalized pediatric patient in a children hospital. The medical case history has special medical, legal, and financial importance in pediatrics. The student's educational pediatric medical case history contains the same sections as the official pediatric’s medical case history, but it is more detailed. The aim of our work was was to analyze student pediatric medical case histories, to determine the features of writing pediatric medical case histories in modern conditions, and to suggest possible ways to optimize this direction of studentsʼ studies. The peculiarities of writing a student's pediatric medical case history in modern conditions are the limited time of communication between the student and the pediatric patient. Certain difficulties in writing an educational student’s pediatric medical case history by a student are caused by the lack of a single unified classical scheme. An important feature is also that students have limited opportunity to observe a pediatric patient in dynamics when receiving a patient for supervision. Students very often use various Internet resources when writing an educational pediatrics medical case history, which do not quite correspond to the classic doctor’s scheme of writing a pediatric medical case history. The development of updated educational methodological recommendations for writing a pediatric patient's medical case history with a consistent brief description of the content of the main sections, using the most modern protocols for the diagnosis, treatment, and rehabilitation in pediatrics will provide an opportunity to improve students' understanding of the correct scheme for writing medical documentation.