Annotation

The article analyzes systemic issues in the documentation support of medical care in surgical inpatient settings, with a focus on medico-legal aspects. It examines deficiencies in the regulatory framework governing the maintenance of the inpatient medical record (Form No. 003/u). Particular attention is paid to gaps in the regulation of informed voluntary consent – specifically, the absence of federally approved standardized consent forms for most medical interventions and for the disclosure of confidential medical information. The article also analyzes the risks associated with the blurring of boundaries between a clinical case conference (consilium) and a medical board, which may render decisions legally void and diminish individual accountability. Legal uncertainty following the repeal of the Russian Ministry of Healthcare Order No. 203n dated May 10, 2017 – particularly regarding timeframes and procedural requirements for diagnosis and treatment in surgical departments – is highlighted. The paper further underscores documentation challenges in intensive care and resuscitation units, prescription of narcotic and psychotropic drugs, cardiopulmonary resuscitation procedures, refusals of hospitalization, and notification of a patient’s death. In conclusion, the authors propose measures to address these gaps: adoption of standardized federal documentation templates, development of local institutional protocols, implementation of digital solutions, and enhanced legal training for healthcare personnel.