Diets by order 330. Normative legal documents. Organization of medical nutrition at the federal level

White cabbage is excluded from the sparing diet and its content in other standard diets is slightly reduced. In addition, rye bread is excluded from the sparing diet, which is contraindicated in a number of inflammatory diseases of the gastrointestinal tract, at the same time, the amount of wheat bread, starch, pasta and potatoes has been increased.

According to the new standards in medical nutrition, the number of cereals for making soups, cereals, side dishes has been increased. There are more vegetables - cucumbers and tomatoes, as well as fermented milk products, coffee and cocoa.

The composition of components for the preparation of dietary meals also includes protein composite dry mixes.

Approaches to the creation of dry protein composite mixtures and their formulation were developed back in the 70s of the last century by Academician A.A. Pokrovsky. These products are made on the basis of milk whey proteins with the inclusion of lecithin, polyunsaturated fatty acids, dietary fiber, vitamins and minerals, maltodextrin (a source of carbohydrates).
Dry protein composite mixtures include a well-balanced and easily digestible protein, the source of which is not soy, but milk whey proteins. At the same time, they do not contain animal fat, the excessive consumption of which leads to the development of atherosclerosis and overweight.
The effectiveness of their inclusion in dietary meals for many cardiovascular diseases, diabetes mellitus, liver diseases, metabolic disorders and other diseases is confirmed by the results of clinical trials, which were carried out for two years at the Research Institute of Nutrition of the Russian Academy of Medical Sciences, Federal State Budgetary Institution Central Research Institute of Tuberculosis "RAMS, etc.
Dry protein composite mixtures are produced in accordance with GOST R 53861-2010 “Dietary (therapeutic and prophylactic) food products. Dry protein composite mixtures. General technical conditions ".
Mixtures are added to State Register and are used as a component for the preparation of medical and preventive nutrition for children from 3 years old and adults, and workers employed in work with harmful and especially harmful conditions labor.
Dry protein composite mixtures were introduced into medical and sanatorium nutrition in accordance with the previous standards for six standard diets, which were approved by the Order of the Ministry of Health of Russia in 2003 (Order of the Ministry of Health of Russia dated August 5, 2003 N 330 "On measures to improve medical nutrition in medical institutions Russian Federation») With changes as of April 26, 2006, introduced by orders of the Ministry of Health and Social Development of Russia No. 2 of January 10, 2006. and No. 316 dated 26.04.2006.

The norms approved by the order were developed by specialists of the Federal State Budgetary Institution "Research Institute of Nutrition" of the Russian Academy of Medical Sciences with the involvement of practical nutritionists, specialists in therapeutic nutrition.

When developing the average daily food sets of standard diets, the characteristics of their chemical composition and energy value are taken as a basis, and the nature of the disease is taken into account. Development is based on innovative technologies in the field of medical nutrition. All this, including the introduction of easily digestible components into the diet, allows the body to provide the necessary nutrients.

The draft order was publicly discussed on the Unified Information Disclosure Portal on the preparation by federal executive authorities of draft regulatory legal acts and the results of their public discussion. There were no comments or suggestions to the draft order.

www.rosminzdrav.ru

330 order of the ministry of health

MEDICINE AND LAW

HERE MAY BE

Rules for storage, accounting and dispensing of narcotic drugs and special prescription forms in pharmacy warehouses (bases)

1. Narcotic drugs, regardless of the dosage form, should be stored in warehouses (bases) that have permission from the Standing Committee on Drug Control (PCCN) to work with them. Premises for storing narcotic drugs must meet the current standard requirements for technical strength (Appendix 1).

Administration note: amendment of clause 1.

2. The room for storing narcotic drugs at the end of the work should be locked and sealed or sealed, and the keys, seal and seal should be kept by the person in charge of storing narcotic drugs.

H. Responsibility for organizing the correct storage, safety of narcotic drugs and special prescription forms rests with the head of the pharmacy warehouse (base).

4. Access to the room where narcotic drugs and special prescription forms are stored is allowed only to persons directly working with them, which is formalized by the order of the head of the warehouse (base) and special admission from the ATC authorities.

5. Upon receipt of narcotic drugs, the head of the warehouse (base) or his deputy is obliged to personally verify the compliance of the received quantities with the accompanying documents.

6. Narcotic drugs are dispensed from the warehouse (base) only in a sealed form, with a label indicating the sender, the name of the content and the analysis number attached to each package.

7. The release of narcotic drugs must be carried out according to the requirements signed by the head of the institution or his deputy and certified by the seal of the institution.

All claims and invoices for narcotic medicinal products must be written out separately from claims and invoices for other medicinal products, indicating the quantities in them in words.

Administration note: changes to clause 7.

8. Issuance of narcotic drugs is carried out under a separate power of attorney, drawn up in established order, indicating the name of the funds received and the amount in words. The power of attorney is valid for 15 days.

9. Before dispensing narcotic medicinal products, the financially responsible person must personally check the basis of the day of dispensing, the compliance of the dispensed narcotic medicinal product with the accompanying document, correct packaging and sign a copy of the invoice remaining in the warehouse (base).

Administration note: changes to clause 9.

10. Narcotic drugs are dispensed from pharmacy warehouses (bases) only for medical purposes to treatment-and-prophylactic and pharmaceutical (pharmacy) organizations, as well as research institutions and medical educational institutions that have hospital beds.

Administration note: changes to clause 10.

11. Narcotic drugs, regardless of the dosage form, are recorded in warehouses (bases) in a numbered and laced book (according to the attached form), sealed with a wax seal and signed by the head of the pharmaceutical organization management body of the constituent entity of the Russian Federation.

Administration note: new edition paragraph 11.

12. All documents on the arrival and consumption of narcotic drugs in the warehouse (base) must be kept in a closed and sealed safe by the person responsible for their storage, in accordance with the established storage periods.

Administration note: changes to clause 12.

13. The storage of narcotic drugs that are not approved for use in medical practice in the Russian Federation in pharmacy warehouses (bases) is prohibited.

14. Transportation of narcotic drugs is carried out in accordance with current special rules.

Head of Organization Department

Provision of medicines and

drug control committee

Pharmacy warehouse (base) name

accounting of narcotic drugs in pharmacy warehouses (bases)

Administration note: The book of accounting of narcotic drugs in pharmacy warehouses (bases) is excluded.

Product name ______________________________________________

Unit of measurement __________________________________________________

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Legislative base of the Russian Federation

Free consultation

Federal legislation

• "Health", N 3, 1998

ORDER of the Ministry of Health of the Russian Federation of 12.11.97 N 330 "ON MEASURES TO IMPROVE ACCOUNTING, STORAGE, PRESCRIBING AND USE OF NARCOTIC DRUGS"

In order to streamline the accounting, storage, prescribing and use of narcotic drugs, I order:

1. Put into operation:

- Typical requirements for technical strength and security equipment - fire alarm premises with the storage of drugs (Appendix 1).

- Form of a special prescription form for a narcotic drug (Appendix 2).

- Estimated standards for the need for narcotic drugs for outpatients and inpatients (Appendix 3).

- Rules for storage and accounting of narcotic drugs in pharmacies (Appendix 4).

- Rules for the storage and accounting of narcotic drugs and special prescription forms in medical and preventive institutions (Appendix 5).

- Regulation on the write-off and destruction of narcotic drugs and special prescriptions not used by cancer patients (Appendix 6).

- Rules for storage, accounting and dispensing of narcotic drugs and special prescription forms for narcotic drugs in pharmacy warehouses (bases) (Appendix 7).

- Rules for storage and accounting of narcotic drugs in control and analytical laboratories (Appendix 8).

- Rules for the storage and accounting of narcotic drugs in research institutes, laboratories and educational institutions (Appendix 9).

- Act on the destruction of used ampoules of narcotic drugs (Appendix 10).

- The form of an extraordinary report submitted to the Ministry of Health of the Russian Federation on theft and theft of drugs from pharmacies and medical and prophylactic institutions (Appendix 11).

2.2. To the heads of healthcare authorities and pharmaceutical organizations in the constituent entities of the Russian Federation:

2.1. To impose personal responsibility on the heads of medical and prophylactic institutions for accounting, preservation, dispensing, prescribing and using narcotic drugs and special prescription forms, in accordance with Appendices 1-11 introduced by this Order.

2.2. Provide medical and prophylactic institutions with special prescription forms for narcotic drugs obtained from pharmacy warehouses (bases). The stock of special prescription forms for narcotic drugs in health authorities and medical and prophylactic institutions should not exceed the monthly requirement.

2.3. To oblige the heads of medical and prophylactic institutions (or their deputies) to ensure the storage of special prescription forms for narcotic drugs only in a safe, the key to which must be in the possession of these managers; and exercise systematic control over the prescription of narcotic drugs and the established procedure for their prescription (Appendix 2). Strictly prohibit doctors from issuing, as well as writing out prescriptions for narcotic drugs to patients suffering from drug addiction.

2.4. To oblige the attending physicians to register the appointment and use of narcotic drugs with records in the medical history indicating the name of the drug dosage form, its amount and dosage.

2.5. To oblige the attending or doctors on duty to hand over used ampoules of narcotic drugs on the same day, with the exception of weekends and holidays, the deputy head for the medical part, and in institutions where he is absent - the head of the medical and prophylactic institution. The destruction of the used ampoules is carried out by a commission chaired by the head with the execution of the corresponding act in the prescribed form (Appendix 7).

3. The Standing Committee on Drug Control, heads of medical and prophylactic institutions, heads of research institutions, when determining the need for narcotic drugs, should be guided by the consumption rates of narcotic drugs (Appendix 9).

4. The heads of public health authorities and pharmaceutical organizations in the constituent entities of the Russian Federation systematically organize checks on the correctness of the appointment and registration of persons admitted (including temporarily) to work on the receipt, storage, accounting and dispensing of narcotic drugs in pharmacies and medical and preventive institutions ... If facts of violation of the procedure for prescribing and admitting persons to work with narcotic drugs are revealed, the perpetrators are brought to strict liability in accordance with the legislation of the Russian Federation.

5. The heads of public health authorities and pharmaceutical organizations in the constituent entities of the Russian Federation shall bring this Order to the attention of medical and pharmaceutical workers and exercise constant control over its implementation.

6. Consider the Order of the Ministry of Health of the USSR of 12/30/82 N 1311 "On measures to eliminate serious shortcomings and further strengthen the fight against drug addiction, improve the accounting, storage, prescribing and use of narcotic drugs" (Appendix 2 "Form a special prescription form for a narcotic drug ", Appendix 3" Norms of consumption of narcotic drugs ", Appendix 4" Form of an extraordinary report submitted to the USSR Ministry of Health on theft and theft of drugs from pharmacies and medical and prophylactic institutions ", Appendix 5" Storage rules and accounting of narcotic drugs in self-supporting pharmacies ", Appendix 6" Rules for the storage and accounting of narcotic drugs and special prescription forms in medical and preventive institutions ", Appendix 7" Rules for the storage, accounting and dispensing of narcotic drugs and special recipes nourishing forms for narcotic drugs in pharmacy warehouses ", Appendix 8" Rules for the storage and accounting of narcotic drugs in control and analytical laboratories of pharmacy departments ", Appendix 9" Rules for the storage and accounting of narcotic drugs in research institutes, laboratories and educational institutions of the health care system " , Appendix 10 “Regulations on the disposal and destruction of narcotic drugs and special prescriptions not used by cancer patients”, Appendix 11 “Act on the destruction of used ampoules of narcotic drugs in health care institutions”).

7. Control over the implementation of this Order shall be entrusted to the Deputy Minister of Health Vilken A.Ye.

Annex 1
APPROVED BY
By order of the Ministry
health care
Russian Federation
dated November 12, 1997 N 330
AGREED
Deputy Minister
internal affairs
Russian Federation
A.N. KULIKOV
March 5, 1993
AGREED
Chairperson
The Standing Committee
drug control
E.A. BABAYAN
March 4, 1993

1.1. These Requirements provide for measures for technical strengthening and determine the basic principles for the creation of multi-border security and fire alarm systems to protect premises (special storage facilities) with drugs included in the lists issued by the Standing Committee on Drug Control.

The requirements apply to projected, newly built and reconstructed drug storage facilities. The technical strength of premises with drugs, the security agreements of which have already been concluded, must be brought into line with the requirements of this document within the time frame established in the acts of commission surveys.

The requirements apply to premises for the storage of potent and toxic substances.

1.2. Commission examinations of drug storages are carried out by representatives of health authorities, security units, State Fire Control and other interested organizations. The Commission, on the basis of the current regulations and the available documentation, determines the places of concentration of narcotic drugs, selects the optimal option for protecting the facility with the help of signaling devices, taking into account its telephone installation and power supply. The survey identifies vulnerabilities in building structures (windows, doors, non-capital walls, ceilings, floors, ventilation openings, etc.), determines the number of security and fire loops, devices, detectors, sensors required to protect drug storage sites.

Based on the results of the examination of the storage of narcotic drugs, an act of the prescribed form is drawn up, the performers and the timing of the work are determined.

1.3. Preparation and execution of work on equipping the premises with drugs with OPS agents should be carried out in accordance with:

- with technological maps and instructions for the installation of security alarm systems and devices;

- VSN 25-09.68-85 “Rules for production and acceptance of works. Installation of security, fire and security - fire alarms ";

- with technical documentation for products;

- with the requirements of PUE, SNiP 2.04.09-84 and SNiP 3.05.06-85.

2.1. Premises with drugs must have walls equivalent in strength to brick walls, at least 510 mm thick, floors and ceilings, equivalent in strength to a reinforced concrete slab with a thickness of at least 100 mm.

2.2. Walls, ceilings, floors that do not meet the specified requirements, from the inside over the entire area, must be reinforced with steel gratings with a diameter of rods of at least 10 mm and a mesh size of no more than 150 x 150 mm. The gratings are welded to anchors with a diameter of at least 12 mm, released from the masonry of the wall or floor slabs, with a pitch of 500 x 500 mm.

If it is impossible to mount the anchors, it is allowed to shoot embedded parts from a steel strip with a size of 100 x 50 x 6 mm to reinforced concrete and concrete surfaces with four dowels.

2.3. Entrance doors storages of narcotic drugs must comply with the requirements of GOST 6629-88, GOST 24698-81, GOST 24584-81, GOST 14624-84, be serviceable, well fitted to the door frame, full-bodied, at least 40 mm thick, have at least two mortise non-self-locking locks ... Doors are upholstered on both sides with sheet metal with a thickness of at least 0.6 mm with a bend of the edges of the sheet on the inner surface of the door or on the edge of the sheet with an overlap. The doorway from the inside is additionally protected by lattice metal doors made of steel bar with a diameter of at least 16 mm, cells of no more than 150 x 150 mm, which are welded at each intersection. The design of the doorway (door frame) is made of a steel profile. In existing storage facilities, wooden boxes are allowed, reinforced with steel corners measuring 30 x 40, at least 5 mm thick, fixed to the wall with reinforcing steel pins with a diameter of 10 - 12 mm and a length of 120 - 150 mm.

2.4. Window openings of premises with drugs from the inside or between the frames are equipped with metal bars, which are made of steel rods with a diameter of at least 16 mm and the distance between the rods vertically and horizontally no more than 150 mm. The ends of the grating rods are embedded in the wall to a depth of at least 80 mm and poured with concrete.

It is allowed to use decorative grilles or blinds, which in terms of strength should not be inferior to the above grilles.

2.5. Narcotic drugs should be kept in safes. In technically fortified premises, it is allowed to store drugs in metal cabinets. Safes (metal cabinets) must be closed. After the end of the working day, they must be sealed or sealed. The keys to the safes, the seal and the sealant must be kept with them by financially responsible persons authorized to do so by orders of health authorities or institutions.

3.1. Drug storage facilities must be equipped with multi-border security alarm systems with each line connected to separate numbers of centralized monitoring consoles.

3.2. The first line of signaling protects the building structures of the perimeters of the premises - window and door openings, ventilation ducts, thermal inputs and other elements of the room accessible for penetration from the outside. Doors are locked for "opening" and "break". Windows are protected by alarms for "opening" and "breaking" glass. Non-capital walls, ceilings, communication entry points - on the "break". Capital walls, ventilation ducts - for "destruction" and "impact".

It is recommended to block building structures for "opening" (windows, doors) with detectors of the SMK type; Non-capital walls (partitions) are protected against a break with a PEL wire. To block the main walls and ceiling of the room, it is recommended to use a detector of the Gran-1 type, which allows detecting the destruction of building structures made of bricks of at least 150 mm and concrete with a thickness of at least 120 mm. Vulnerable areas of premises perimeters can be protected by optical - electronic detectors such as "Foton-2", "Foton-5", which form a detection zone in the form of a vertical barrier.

3.3. Additional alarm lines protect the internal volumes and areas of premises, safes (metal cabinets) used for storing drugs. For additional security lines, the choice of detectors is determined depending on the nature of the premises and the location of material assets in them. Ultrasonic, optical-electronic, radio wave, capacitive detectors "Echo-2,3", "Foton-1M, 4", "Kvant-3", "Volna-2, M", " Background-1 "," Rif-M "," Peak ", etc.

To increase the reliability of the burglar alarm actuation, it is recommended to use detectors of different operating principles.

3.4. In multi-foreign protection systems, control and monitoring devices should be used to monitor alarm loops in case of power failure. The use of control and monitoring devices and detectors with autonomous power supply or units for switching to power from the centralized monitoring console via telephone lines in conjunction with object devices of the compaction equipment, which do not provide backup power, is impractical.

3.5. In addition to independent protection lines, it is recommended to equip safes (metal cabinets) with trap sensors directly, which are included in the loop of the additional alarm line.

3.6. When the mains power supply is disconnected, the operability of the control panel, sensors and detectors of one of the alarm lines must be ensured. If there are no telephone lines in the storages, it is necessary to use HF multiplexing of free lines of the distribution network, telephone lines of organizations, citizens' apartments located near the store, or payphone lines.

3.7. At large facilities (bases, warehouses) with the storage of narcotic drugs, it is allowed to use the principle of "low centralization" with the installation of small-capacity concentrates in the control - checkpoints with their connection to centralized monitoring consoles.

3.8. Workplaces of personnel engaged in drug operations, as well as storage facilities, are equipped with alarms, which are designed to transmit alarm signals to the duty units of the internal affairs bodies and to take measures in the event of a robbery during working hours.

3.9. The fire alarm system must provide round-the-clock operation. Fire detectors are included in general or independent blocking loops connected to general or independent devices with alarm signals output to centralized monitoring panels or local sound and light signaling devices.

3.10. At facilities (in rooms) with the storage of narcotic drugs, it is not allowed to use security alarm equipment that is not included in the List of technical means of security, security - fire and fire alarms recommended for use.

4. Compliance with the provisions of these Model Requirements is mandatory upon obtaining permission from the Standing Narcotics Control Board to possess narcotic drugs.

Appendix 2
APPROVED BY
By order of the Ministry
health care
Russian Federation
dated November 12, 1997 N 330

Appendix 3
APPROVED BY
By order of the Ministry
health care
Russian Federation
dated November 12, 1997 N 330

CALCULATION STANDARDS FOR NARCOTIC DRUG NEEDS
PER 1000 POPULATION PER YEAR (IN GRAMS)

Order of the Ministry of Health of Russia dated 05.08.2003 N 330 (as amended on 24.11.2016) "On measures to improve medical nutrition in medical institutions of the Russian Federation" (together with the "Regulations on the organization of the activity of a nutritionist dietetic nurse "," Regulations on the Council for Medical Nutrition of Medical and Prophylactic Institutions "," Instructions for the Organization of Medical Nutrition in Medical and Prophylactic Institutions ") (Registered in the Ministry of Justice of Russia on 12.09.2003 N 5073)

MINISTRY OF HEALTH OF THE RUSSIAN FEDERATION

ABOUT IMPROVEMENT MEASURES

MEDICAL NUTRITION IN MEDICAL AND PREVENTIVE

INSTITUTIONS OF THE RUSSIAN FEDERATION

In order to implement the Concept of state policy in the field of healthy nutrition of the population of the Russian Federation for the period up to 2005, approved by the Decree of the Government of the Russian Federation of 10.08.1998 N 917 "*", to improve the organization of medical nutrition and increase the effectiveness of its application in the complex treatment of patients, I order:

"*" Collected Legislation of the Russian Federation, 08.24.1998, N 8, Art. 4083.

1.1. Regulations on the organization of the activity of a dietitian (Appendix No. 1);

1.2. Regulations on the organization of the activities of a dietetic nurse (Appendix No. 2);

1.3. Regulations on the Council for Medical Nutrition in Medical and Prophylactic Institutions (Appendix No. 3);

1.4. Instructions for the organization of medical nutrition in medical institutions (Appendix No. 4);

1.5. Instructions for the organization of enteral nutrition in medical institutions (Appendix No. 5).

2. Control over the implementation of this Order shall be entrusted to the Deputy Minister R.А. Khalfina.

ABOUT THE ORGANIZATION OF ACTIVITIES OF THE DIET STUDENT

1. The position of a dietitian is a specialist doctor who is trained in therapeutic nutrition and a certificate in the specialty "dietetics".

2. A dietitian is responsible for the organization of nutritional therapy and its adequate use in all departments of health care institutions.

3. The dietitian supervises the dietary nurses, supervises the work of the catering unit.

4. The dietitian must:

a) advise the doctors of the departments on the organization of medical nutrition;

b) advise patients on therapeutic and rational nutrition;

c) conduct a random check of medical records for the compliance of the prescribed diets and the stages of diet therapy;

d) analyze the effectiveness of therapeutic nutrition;

e) check the quality of products when they arrive at the warehouse and catering unit; control the correct storage of food supplies;

f) exercise control over the correctness of the laying of products when preparing dishes;

g) prepare documentation for the organization of medical nutrition:

- seven-day consolidated menu - summer and winter options;

h) control the correctness of the documentation nurse dietary (layout menu, requirement menu, etc.);

i) exercise control over the quality of finished food before issuing it to the departments by taking a sample at each meal;

j) together with the heads of departments, determine the list and number of food parcels at home for a patient being treated in a medical and prophylactic institution;

k) control the timeliness of preventive medical examinations of workers in the catering and canteens and prevent persons who have not undergone preventive medical examinations and patients with pustular, intestinal diseases, angina from working;

l) systematically organize the improvement of the level of qualifications of the catering department workers on the issues of medical nutrition;

m) to carry out active sanitary and educational work on rational and therapeutic nutrition for all employees of a medical institution and patients;

o) improve the level of professional qualifications in the cycles of improvement in dietetics at least once every 5 years.

ABOUT ORGANIZATION OF MEDICAL ACTIVITIES

1. The position of a dietetic nurse is a specialist with a secondary medical education, who has special training in therapeutic nutrition and a certificate in the specialty "dietetics".

2. A dietetic nurse works under the guidance of a dietitian.

3. The dietetic nurse monitors the work of the catering unit and the observance of sanitary and hygienic rules by the employees of the food unit.

4. A dietetic nurse is obliged to:

a) check the quality of products when they arrive at the warehouse and catering unit; control the correct storage of food supplies;

b) prepare daily, under the supervision of a dietitian and with the participation of the production manager, a layout menu (or a demand menu) in accordance with a card index of dishes and a consolidated menu approved by the Health Nutrition Council;

c) monitor the correctness of the bookmark of products during cooking and rejection finished products, take a sample of finished food;

d) control the correct delivery of dishes from the catering unit to the departments in accordance with the "distribution sheet";

e) exercise control over: the sanitary condition of the premises of the catering unit, handouts, pantries, inventory, dishes, as well as the fulfillment of the rules of personal hygiene by the employees of the catering unit;

f) organize and personally participate in conducting classes with nurses and catering workers on the issues of medical nutrition;

g) keep medical records;

h) to carry out timely preventive medical examinations of employees of the catering department, dispensers and pantries and not to allow persons who have not undergone a preventive medical examination and patients with pustular, intestinal diseases, sore throat to work;

i) increase the level vocational training at least once every 5 years.

dated 05.08.2003 N 330

ABOUT THE ADVICE ON HEALING NUTRITION

1. The Council for Curative Nutrition is an advisory body and is created in a medical and prophylactic institution with a number of beds from 100 and more.

2. The number of members of the Council for Medical Nutrition and its personal composition is approved by the order of the chief physician of the institution.

3. The Council for Curative Nutrition includes: the chief physician (or his deputy for curative work) - the chairman; dietitian - executive secretary, heads of departments - doctors, doctors anesthesiologist-resuscitator, gastroenterologist, therapist, transfusiologist, surgeon (members of the nutrition support team), deputy chief physician for economic affairs, dietary nurses, production manager (or chef) ... If necessary, other specialists of the medical and prophylactic institution may be involved in the work of the Council.

4. Tasks of the Nutritional Health Council:

a) improving the organization of medical nutrition in a medical and prophylactic institution;

b) introduction of new technologies for preventive, dietary and enteral nutrition;

d) approval of the nomenclature of diets, mixtures for enteral nutrition, protein composite dry mixtures for medical nutrition, biologically active additives to be introduced in this health care institution;

e) approval of seven-day menus, a card index of dishes and a set of mixtures for enteral nutrition;

g) improvement of the ordering system for dietary kits and mixtures for enteral nutrition;

h) development of forms and plans for professional development of employees in therapeutic nutrition;

i) control over the organization of medical nutrition and analysis of the effectiveness of diet therapy for various diseases.

5. The Nutritional Medicine Council meets as needed, but at least once every three months.

ON ORGANIZATION OF MEDICAL NUTRITION

IN MEDICAL AND PREVENTIVE INSTITUTIONS

The organization of medical nutrition in a medical and prophylactic institution is an integral part of the treatment process and is one of the main therapeutic measures.

In order to optimize therapeutic nutrition, improve the organization and improve its quality management in medical institutions, a new nomenclature of diets (a system of standard diets) is being introduced, differing in the content of basic nutrients and energy value, cooking technology and the average daily set of products.

Previously used diets of the numbered system (diets N N 1 - 15) are combined or included in the system of standard diets, which are prescribed for various diseases, depending on the stage, severity of the disease or complications from various organs and systems (Table 1).

Along with the basic standard diet and its variants in the health care facility, in accordance with their profile, the following are used:

- surgical diets (0-I; 0-II; 0-III; 0-IV; diet for ulcerative bleeding, diet for stomach stenosis), etc.;

- specialized diets: a high-protein diet with active tuberculosis (hereinafter referred to as a high-protein diet (t));

- unloading diets (tea, sugar, apple, rice-compote, potato, curd, juice, meat, etc.);

- special diets (potassium, magnesium, probe diet, diets for myocardial infarction, diets for unloading and dietary therapy, vegetarian diet, etc.).

The individualization of the chemical composition and calorie content of standard diets is carried out by selecting the medical nutrition dishes available in the card index, increasing or decreasing the number of buffet products (bread, sugar, butter), monitoring food home transfers for patients undergoing treatment in a medical institution, as well as by use of biologically active food supplements and ready-made specialized mixtures in medical and enteral nutrition. To correct the diet, 20-50% of the protein of ready-made specialized mixtures can be included (Table 1a).

The purchase of dry protein composite mixtures for therapeutic nutrition is carried out in accordance with the Instructions on the procedure for applying the budget classification of the Russian Federation, approved by Order of the Ministry of Finance of the Russian Federation dated December 21, 2005 N 152n (in accordance with the letter of the Ministry of Justice of the Russian Federation dated January 10, 2006 No. N 01/32-ЕЗ The order does not need state registration) according to article 340 of the economic classification of expenditures of the budgets of the Russian Federation "Increase in the cost of inventories" with the referral of ready-made specialized mixtures for therapeutic nutrition to the section "food (payment for food), including food rations to servicemen and persons equated to them ”.

The nomenclature of permanent diets in each medical institution is established in accordance with its profile and is approved by the Council for Clinical Nutrition. In all medical and prophylactic institutions, at least four meals a day are established, according to indications in individual departments or for certain categories of patients (duodenal ulcer, surgery stomach disease, diabetes mellitus, etc.), more frequent meals are used. The diet is approved by the Council on Nutritional Medicine.

The recommended average daily food sets are the basis for the preparation of standard diets in a health care facility (Table 2). When forming standard diets for children and adults receiving spa treatment, more expensive varieties of products are used, taking into account the daily nutritional norms in sanatoriums and sanatoriums-dispensaries (Tables 3, 4, 5). In the absence of a complete set of products at the catering unit, provided for by the consolidated seven-day menu, it is possible to replace one product with another while maintaining the chemical composition and energy value of the therapeutic diets used (Tables 6, 7).

The control of the correctness of the diet therapy should be carried out by checking the compliance of the diets received by patients (in terms of the range of products and dishes, cooking technology, chemical composition and energy value) with the recommended characteristics of standard diets and by checking the uniform use of appropriations by quarters of the year.

The general management of the diet in a medical and preventive institution is carried out by the chief physician, and in his absence - by the deputy for the medical part.

The nutritionist is responsible for the organization of medical nutrition. In cases where there is no position of a dietitian in a health care facility, a dietary nurse is responsible for this work.

Subordinate to the dietitian are dietary nurses and all employees of the catering department who provide medical nutrition in a medical and preventive institution in accordance with this Order.

At the catering unit of a medical and prophylactic institution, control over the observance of the cooking technology and the output of ready-made dietary meals is carried out by the head of production (chef, chief cook), control over the quality of ready-made dietary meals is a dietitian doctor, a dietary nurse, a doctor on duty, authorizing the issuance of ready-made food in the compartments.

All issues related to the organization of medical nutrition in a medical and prophylactic institution are systematically (at least 1 time per quarter) heard and resolved at meetings of the Council for Medical Nutrition.

to the Instructions for organizing

CHEMICAL COMPOSITION AND ENERGY

THE VALUE OF STANDARD DIETS USED IN HEALTHCARE

Act for the destruction of used ampoules of narcotic drugs and psychotropic substances (Appendix 10). (as amended by the Order of the Ministry of Health of the Russian Federation of 05.16.2003 N 205)

The form of an extraordinary report submitted to the Ministry of Health of the Russian Federation on theft and theft of drugs from pharmacies and medical and prophylactic institutions (Appendix 11).

2.2. To the heads of healthcare authorities and pharmaceutical organizations in the constituent entities of the Russian Federation:

2.1. To impose on the heads of medical and prophylactic institutions personal responsibility for accounting, preservation, dispensing, prescribing and using narcotic drugs and psychotropic substances and special prescription forms, in accordance with Appendices 1-11 introduced by this Order. (as amended by the Order of the Ministry of Health of the Russian Federation of 05.16.2003 N 205)

2.2. Provide medical and prophylactic institutions with special prescription forms for narcotic drugs and psychotropic substances obtained from pharmacy warehouses (bases). The stock of special prescription forms for narcotic drugs and psychotropic substances in health authorities and medical and prophylactic institutions should not exceed the monthly requirement. (as amended by the Order of the Ministry of Health of the Russian Federation of 05.16.2003 N 205)

2.3. To oblige the heads of medical and prophylactic institutions (or their deputies) to ensure the storage of special prescription forms for narcotic drugs only in a safe, the key to which must be in the possession of these managers; and exercise systematic control over the prescription of narcotic drugs and psychotropic substances and the established procedure for their prescription (Appendix 2). Strictly prohibit doctors from issuing, as well as writing out prescriptions for narcotic drugs and psychotropic substances to patients suffering from drug addiction. (as amended by the Order of the Ministry of Health of the Russian Federation of 05.16.2003 N 205)

2.4. To oblige the attending physicians to prescribe and use narcotic drugs and psychotropic substances, regardless of the dosage form, to draw up records in the medical history and prescription sheet indicating the name of the dosage form of the narcotic drug and psychotropic substance, its amount and dosage. (as amended by the Order of the Ministry of Health of the Russian Federation of 05.16.2003 N 205)

2.5. To oblige the attending doctors or doctors on duty to hand over used ampoules of narcotic drugs and psychotropic substances on the same day, with the exception of weekends and holidays, to the deputy head for the medical department, and in institutions where he is absent - to the head of the medical and preventive institution. The destruction of used ampoules should be carried out at least once every 10 days by a commission chaired by the head with the execution of the corresponding act in the prescribed form (Appendix 10). (as amended by the Order of the Ministry of Health of the Russian Federation of 05.16.2003 N 205)

3. The Standing Committee on Drug Control, heads of medical and preventive institutions, heads of research institutions, when determining the need for narcotic drugs and psychotropic substances, should be guided by the consumption rates of narcotic drugs and psychotropic substances (Tables 2 and 3). (as amended by the Order of the Ministry of Health of the Russian Federation of 05.16.2003 N 205)

4. The heads of public health authorities and pharmaceutical organizations in the constituent entities of the Russian Federation shall systematically organize checks on the correctness of the appointment and registration of persons admitted (including temporarily) to work on the receipt, storage, accounting and dispensing of narcotic drugs and psychotropic substances in pharmaceutical and medical - preventive institutions. If facts of violation of the procedure for the appointment and admission of persons to work with narcotic drugs and psychotropic substances are revealed, the perpetrators are brought to strict liability in accordance with the legislation of the Russian Federation. (as amended by the Order of the Ministry of Health of the Russian Federation of 05.16.2003 N 205)

5. The heads of public health authorities and pharmaceutical organizations in the constituent entities of the Russian Federation shall bring this Order to the attention of medical and pharmaceutical workers, and exercise constant control over its implementation.

6. Consider the Order of the Ministry of Health of the USSR of 12/30/82 N 1311 "On measures to eliminate serious shortcomings and further strengthen the fight against drug addiction, improve the accounting, storage, prescribing and use of narcotic drugs and psychotropic substances" (Appendix 2 "Form of a special prescription form for a narcotic drug and psychotropic substance", Appendix 3 "Consumption rates of narcotic drugs and psychotropic substances", Appendix 4 "Form of an extraordinary report submitted to the USSR Ministry of Health on theft and theft of drugs from pharmacies and medical and prophylactic institutions" , Appendix 5 "Rules for the storage and accounting of narcotic drugs and psychotropic substances in self-supporting pharmacies", Appendix 6 "Rules for the storage and accounting of narcotic drugs and psychotropic substances and special prescription forms in medical and preventive institutions", Appendix 7 "Rules for storage, accounting and dispensing drugs drugs and psychotropic substances and special prescription forms for narcotic drugs in pharmacy warehouses ", Appendix 8" Rules for the storage and accounting of narcotic drugs in control and analytical laboratories of pharmaceutical departments ", Appendix 9" Rules for the storage and accounting of narcotic drugs in research institutes, laboratories and educational institutions of the health care system ", Appendix 10" Regulations on the write-off and destruction of narcotic drugs and psychotropic substances and special prescriptions not used by cancer patients ", Appendix 11" Act for the destruction of used ampoules of narcotic drugs and psychotropic substances in health care institutions "). (as amended by the Order of the Ministry of Health of the Russian Federation of 05.16.2003 N 205)

7. Control over the implementation of this Order shall be entrusted to the Deputy Minister of Health Vilken A.Ye.

The minister
T.B. DMITRIEVA

AGREED
Deputy Minister
internal affairs
Russian Federation
A.N. KULIKOV
March 5, 1993

AGREED
Chairperson
The Standing Committee
drug control
E.A. BABAYAN
March 4, 1993

APPENDIX 1. STANDARD REQUIREMENTS FOR TECHNICAL STRENGTHENING AND EQUIPMENT WITH SECURITY AND FIRE SIGNALING ROOMS WITH STORAGE OF NARCOTIC DRUGS - Abolished. dated 17.11.2010 N 1008н)

Appendix 2
APPROVED BY
By order of the Ministry
health care
Russian Federation
dated November 12, 1997 N 330

APPENDIX 2. FORM OF A SPECIAL PRESCRIPTION FORM FOR A NARCOTIC DRUG AND PSYCHOTROPIC SUBSTANCE - No longer valid. (as amended by the Order of the Ministry of Health and Social Development of the Russian Federation of November 17, 2010 N 1008n)

Appendix 3
APPROVED BY
By order of the Ministry
health care
Russian Federation
dated November 12, 1997 N 330

dated 09.01.2001 N 2, dated 16.05.2003 N 205)

Table 1

ESTIMATED STANDARDS FOR NARCOTIC DRUGS AND PSYCHOTROPIC SUBSTANCES PER 1000 POPULATION PER YEAR (IN GRAMS)

(as amended by the Order of the Ministry of Health of the Russian Federation of 05.16.2003 N 205)

Note. The standards are established by recalculating all dosage forms for a purely active substance, and therefore, when comparing the application with the estimated need according to the standards, it is necessary to recalculate all dosage forms containing these substances for a purely active drug.

Chairperson
The Standing Committee
drug control
E.A. BABAYAN

table 2

ESTIMATED STANDARDS FOR NARCOTIC DRUGS AND PSYCHOTROPIC SUBSTANCES PER BED PER YEAR

(as amended by the Order of the Ministry of Health of the Russian Federation of 05.16.2003 N 205)

<*>The consumption rate of fentanyl 0.005% per patient operated on under general anesthesia is within 18 ampoules.

<**>The standards for prosidol for medical practice in surgical, traumatological, oncological, dental, gynecological, medical and prophylactic institutions were approved by analogy with the calculated standards for promedol.

Notes:

1) The heads of the healthcare management bodies of the constituent entities of the Russian Federation are allowed, according to the recommendations of the heads of medical and preventive institutions, to increase the calculated standards given in this table, but not more than 1.5 times. (as amended by the Order of the Ministry of Health of the Russian Federation of 09.01.2001 N 2)

2) The heads of medical and prophylactic institutions are allowed to redistribute between the departments the narcotic drugs and psychotropic substances indicated in this table within the general standard of need for the institution for each name. (as amended by the Orders of the Ministry of Health of the Russian Federation of 09.01.2001 N 2, of 16.05.2003 N 205)

3) In the presence of medical indications for the relief of severe pain syndrome in the departments of medical and preventive institutions indicated in this table, it is allowed to use non-invasive forms of narcotic drugs and psychotropic substances in quantities corresponding to medical indications and the patient's condition. (as amended by the Orders of the Ministry of Health of the Russian Federation of 09.01.2001 N 2, of 16.05.2003 N 205)

Chairperson
The Standing Committee
drug control
E.A. BABAYAN

Table 3

CALCULATION STANDARDS
NEEDS OF NARCOTIC DRUGS AND PSYCHOTROPIC SUBSTANCES PER ONE BED PER YEAR FOR ONCOLOGICAL DEPARTMENT (CHAMBER) OF PALLIATIVE CARE, MEDICAL - PREVENTIVE INSTITUTION AND HOSPITAL

(as amended by the Orders of the Ministry of Health of the Russian Federation of 09.01.2001 N 2, of 16.05.2003 N 205)

<*>In terms of pure active ingredient.

Note. For each of the paragraphs of this Appendix, it is allowed to exceed the amount of a specific dosage form of a medicinal product within the specified total amount in terms of the pure active substance.

Chairperson
The Standing Committee
drug control
E.A. BABAYAN

Table 4 - Abolished. (as amended by the Order of the Ministry of Health of the Russian Federation of 09.01.2001 N 2)

Appendix 4
APPROVED BY
By order of the Ministry
health care
Russian Federation
dated November 12, 1997 N 330

APPENDIX 4. RULES OF STORAGE AND ACCOUNTING OF NARCOTIC DRUGS AND PSYCHOTROPIC SUBSTANCES IN PHARMACIES - Abolished. (as amended by the Order of the Ministry of Health and Social Development of the Russian Federation of November 17, 2010 N 1008n)

APPROVED BY
By order of the Ministry
health care
Russian Federation
dated November 12, 1997 N 330

MINISTRY OF HEALTH
Khabarovsk Territory

In order to implement the Concept of state policy in the field of healthy nutrition of the population of the Khabarovsk Territory, to improve the organization of medical nutrition in medical institutions of the Territory

I declare:

1. .

I order:

1. To the heads of public health authorities of municipalities, medical and preventive institutions of the region:
1.1. To accept for execution the Order of the Ministry of Health of the Russian Federation of 05.08.2003 N 330 "On measures to improve nutrition in medical institutions of the Russian Federation", bring it to the attention of specialists of subordinate medical institutions.
1.2. Organize a seminar for medical workers of subordinate institutions to study the above Order by 10.06.2004.
1.3. Ensure the introduction of a new nomenclature of diets, use in medical and enteral nutrition with individualization of the chemical composition and calorie content (standard diets, with mechanical and chemical sparing, with an increased amount of protein); decrease or increase in buffet products, biologically active food additives (including soy products , bread from sprouted grain or with lamidan) and ready-made specialized mixtures.
1.4. Equip vacancies dietitians.
1.5. To amend the existing Provisions on the Council for Medical Nutrition, on the organization of the activities of a dietitian, a nurse of a dietary treatment and prophylactic institution.
1.6. Submit an application to the Ministry of Health of the Territory on the need to conduct training on the basis of the Institute for Advanced Training of Healthcare Professionals of the Ministry of Health of the Khabarovsk Territory for doctors and paramedical workers, ensure their referral to specialized courses in the system of postgraduate education.
2. First Deputy Minister of Health of the Khabarovsk Territory Tropnikova V.M. to envisage in the programs of postgraduate training of medical workers the issues of the organization of medical nutrition in medical and prophylactic institutions.
3. To take into consideration the Order of the Ministry of Health of the Russian Federation of 12.02.2004 N 95 "On cancellation of the order of 23.04.1985 N 540 and of 14.06.1989 N 369".
4. Information on the execution of this order shall be submitted by 01.10.2004.
5. Control over the implementation of this order shall be entrusted to the Deputy Minister of Health of the Khabarovsk Territory A.Ya. Derkach.

The process of organizing medical nutrition in medical institutions of our country must be considered from the standpoint of the current federal legislation. For the first time in the Russian legislation, the Federal Law of 21.11.2011 No. 323-FZ "On the Basics of Health Protection of Citizens in the Russian Federation" defines the norms governing the foundations of the organization of medical nutrition.

• Table 3. Documents on the implementation of the main directions of the order of the Ministry of Health of Russia dated 5.08.2003 No. 330

Organization of medical nutrition at the federal level

The organization of medical nutrition at the federal level is carried out in accordance with the requirements of the following regulations:

Federal Law of November 21, 2011 No. 323-FZ "On the Fundamentals of Health Protection of Citizens in the Russian Federation". In accordance with Art. 76 of the Constitution of the Russian Federation, the law has direct effect on the territory of the entire country. In the field of health protection, this law introduces the most general, fundamental norms that require more detailed explanation in departmental orders, methodological recommendations and information letters (see the text of the document on the website www ..

Order of the Ministry of Health and Social Development of Russia dated June 24, 2010 No. 474n "On approval of the Procedure for the provision of medical care to the population in the" dietology "profile". The order is a normative legal document that defines the principles, procedure and system for organizing medical nutrition in the territory of the Russian Federation.

The norms of medical nutrition are the basis for the formation of food rations in diet therapy and at the same time the organization, planning and financing of the entire system of medical nutrition in the institution.

Regulatory documents, the names of which are presented in table. 1, currently operate throughout the territory of our country and are mandatory for medical organizations in the organization of medical nutrition.

The organization of therapeutic and prophylactic nutrition for patients undergoing inpatient treatment must be carried out in all medical organizations with round-the-clock beds and day beds with meals, sanatoriums in accordance with Order of the Ministry of Health of Russia dated 5.08.2003 No. 330 "On measures to improve medical nutrition in medical institutions of the Russian Federation."

The documents approved by this order are mandatory for use in organizing the food system, document circulation, accounting for the consumption of food, prescribing medical nutrition to various categories of patients in accordance with diseases and complications of diseases. One of these documents is an instruction on the organization of medical nutrition in medical institutions. It defines the following norms for the organization of medical nutrition:

• Characteristics, chemical composition and energy value of standard diets used in health care facilities (in hospitals, etc.).
• Ratio natural products food and specialized food in the patient's daily diet.
• Interchangeability of products in the preparation of dietary meals.
• Substitution of products for proteins and carbohydrates.
• The procedure for prescribing food for patients in medical institutions.
• The order of control over the quality of finished food in a medical institution.
• Recommendations for the equipment of catering and canteens.
• Transportation of prepared food.
• Sanitary and hygienic regime of the catering unit and pantries.
• List of catering unit documentation for the discharge of foodniya and control over the quality of finished food in medical institutions.

In connection with the release of Order No. 330, the previously used standards by the ratio of the chemical composition of diets, food interchangeability and food substitution cannot be used in medical facilities... For the first time, a federal departmental order introduced a uniform nomenclature of standard diets for all medical institutions.

Instructions on the organization of enteral nutrition in medical institutions are also mandatory. In order to standardize the conduct of enteral nutrition, this document defines the following requirements:

• indications for the use of enteral nutrition;
• contraindications to the use of enteral nutrition;
• assessment of eating disorders;
• observation card of a patient receiving enteral nutrition (insert in the medical card of an inpatient, registration form 003 / U);
• method for determining the energy needs of the body;
• selection of the composition of mixtures for enteral nutrition;
• requirements for basic nutrients (proteins, fats, carbohydrates), depending on the degree of malnutrition;
• the need for protein in some diseases;
• methods of administration of enteral nutritional mixtures.

Federal Departmental Order of the Ministry of Health of the USSR dated 05.05.1983 No. 530 "On Approval of Instructions for the Accounting of Food Products in Treatment-and-Prophylactic state budget THE USSR"(as amended on 05/17/1984, 12/30/1987) and the Order of the Ministry of Health of Russia dated 05.08.2003 No. 330 "On measures to improve medical nutrition in medical institutions of the Russian Federation" approved the system of accounting and document management. It is necessary to maintain documentation in accordance with the requirements of these orders, since it is not only a system for recording patients supplied to meals, but also a system for spending food, monitoring the spending of financial resources.

All documents on the organization of medical nutrition can be conditionally divided into three groups:

1. Documentation intended for the statement of food products and accounting, the appropriations issued for them.
2. Documents reflecting the control over the health of the catering department employees.
3. Diet service organization documentation (production documentation).

Federal Law of November 21, 2011 No. 323-FZ

"On the basics of protecting the health of citizens in the Russian Federation" Ch. 5 "Organization of health protection" Art. 39 "Health food":

"1. Therapeutic nutrition is nutrition that satisfies the physiological needs of the human body for nutrients and energy, taking into account the mechanisms of the development of the disease, the characteristics of the course of the main and concomitant diseases, and fulfills preventive and therapeutic tasks. "

Federal Law of 21.11.2011 No. 323-FZ "On the Fundamentals of Health Protection of Citizens in the Russian Federation" Ch. 5 "Organization of health protection" Art. 39 "Medical nutrition": "The norms of medical nutrition are approved by the authorized federal executive body."

Table 1. Normative legal documents that are mandatory for medical organizations in the organization of medical nutrition

Documentation of the first group. Documentation intended for the statement of food products and accounting, the appropriations issued for them.

The main reporting forms that are drawn up to provide food for patients admitted to the hospital refer to the documents of the first group.

The main document in this group is a card index of dietary dishes (see the details of this document in the article "Specialized card index of dietary dishes", PD No. 1, or on the website www. documents containing information on the satisfaction of the physiological needs of the human body for nutrients and energy, taking into account the mechanisms of the development of the disease, the characteristics of the course of the main and concomitant diseases. the patient during the day, plan the work of the catering unit, facilitate the implementation of organizational measures, calculate the consumption of products and the appropriations allocated for them.

Seven day summary menu

A seven-day summary menu is drawn up on the basis of the card index. Using a seven-day menu in our work, it is possible to plan the volume of food purchases, organize the work of the catering unit personnel, and develop standards in the preparation of various dishes.

It is recommended to have two menus - autumn-summer and winter-spring, since the range of products changes depending on the season, in addition, some products have different percentage of waste after cold processing (cleaning). Of course, it is allowed to have one seven-day consolidated menu, but then it is necessary to make adjustments to it according to the seasons.

Before drawing up a seven-day menu, it is necessary to develop a nomenclature of diets and approve standard and special diets at the Council on Health Nutrition.

The number of diets and their set should be individual for each institution and adapted to its profile. When compiling a menu, it is very important to take into account the high-quality variety of dishes throughout the day and week as a whole. It is desirable that one dish in its modifications be used as much as possible for various diets.

When compiling the menu, the main attention is paid to the chemical composition of the diets, their energy value, the correct use of natural food norms, the consumption of appropriations for food, the possibility of replacing products in accordance with the replacement tables for protein and fat. When compiling the menu, national characteristics are also taken into account by including appropriate dishes.

Layout card

For each dish made at the catering unit, a layout card must be drawn up in two copies (form No. 1-85), one of which is kept in the accounting department, and the second - by the dietary nurse.

Each layout card contains the following data: the name of the dish, the list of diets for which this dish is recommended to be used; a list of products required for the preparation of this dish; bookmark rates (gross); Net weight; the chemical composition of the dish and the net energy value of the dish, taking into account losses during heat treatment ready-made dish; its estimated cost; cooking technology.

Nomenclature of diets

Standard diets Are diets with a physiological content of proteins, fats and carbohydrates and enriched with vitamin and mineral complexes. Standard diets differ in the content of essential nutrients and energy value, the average daily set of foods used as the main therapeutic diets, and the cooking technologies used.

Special diets are assigned to a specific clinical and statistical group of patients, the condition of which requires the exclusion of certain food products from the therapeutic diet, are formed on the basis of standard diets in accordance with the nosological form of the disease, the phase of the disease. Protein correction of the diet is carried out with dry protein composite mixtures.

There is another type of diet - individual diets... They are assigned to a specific patient, whose condition requires the exclusion of certain food products from the diet. If he has a decrease in body mass index below the standard indicators, then the diet is formed individually in accordance with the nosological form of the disease, the phase of the disease, the need for additional nutrition.

Accounting and reporting documentation

A number of documents that must be kept in a medical institution without fail refer to accounting and reporting documents. In medical institutions, currently, in order to optimize work, automated systems workflow that ensure the implementation of scientifically based principles of dietetics.

Information about the presence of patients, for meals, are submitted in the form of Form No. 22 in accordance with Order No. 330 dated 05.08.2003. This form is the basis for the planning and distribution of patients according to diets and meals.

Basic legal document, on the basis of which food products are discharged from the warehouse to the catering unit for cooking and the allocations for food are spent, this is layout menu(Form No. 44-MZ, Order No. 330 dated 05.08.2003). The last digit in the layout menu is entered by the accounting employee, who calculates the total amount of all products required to prepare all the dishes for their discharge from the warehouse.

Requirement for the issuance of products(Form No. 45-M3, Order No. 330 dated 05.08.2003). This document is drawn up in duplicate. One copy remains after the delivery of products from the storekeeper, according to the second copy, the production manager (chef) receives food from the storekeeper for cooking the next day. Products are stored in the pantry for a daily supply. For them full financial responsibility borne by the production manager (chef). The next day, he distributes food to the cooks according to the dishes they prepare. The second copy is handed over to the counting department for settlements, and is subsequently kept by the production manager.

Requirement to receive buffet products(tea, bread, butter, sugar, etc.) is written out separately according to the same form No. 45-MZ. Buffet products from the warehouse go directly to the departments, bypassing the catering unit.

When the number of patients changes in comparison with the data in the layout menu (or menu-requirements) by more than three people, the dietary nurse prepares "Information on the movement of patients"... In accordance with this document, it is in the form No. 434-fur (with an increase in the number of patients) "Demand for the warehouse" to receive additional products based on the main version of the standard diet. If the number of patients decreases in comparison with the previous day, then the products that were not used for cooking are delivered to the warehouse in the same form with the indication "Return" (except for the products already placed in the kettle when preparing breakfast).

Form No. 23-MZ "Handout sheet for dispensing to food ration departments"(food intake: breakfast, lunch, dinner, etc.). This document serves as the basis for the issuance of ready meals to hospital departments.

It is recommended to hang the menu at the entrance to the dining room so that patients can familiarize themselves with it. Those responsible for the organization of medical nutrition in the hospital should inform patients about the replacement of certain dishes. In the absence of the necessary products, this replacement must be carried out taking into account their nutritional value.

Cumulative statement reflects the actual consumption of all products in the past month. The accountant must prepare it by the 10th day of the next month and submit it to the dietitian or the person responsible for the organization of therapeutic nutrition for the analysis of the fulfillment of natural food norms. By the 15th nutritionist or the person responsible for the organization of medical nutrition is obliged to inform the chief physician about the state of compliance with food standards and, if there are any deficiencies, take measures to eliminate them.

Second group documentation. Documents reflecting the control over the health status of the employees of the catering department

The documents reflecting the monitoring of the health status of the employees of the catering department belong to the second group of documents on the organization of medical nutrition.

Each of the employees of the catering unit must have:

• "Personal medical book catering unit worker "(form No. 1-lp, order No. 330 dated 05.08.2003).
• "Journal of Medical Research". This journal is kept by a dietetic nurse, who is obliged to monitor the timeliness of medical research by all employees of the food department.
• Journal "Health" (form No. 2-lp, order No. 330 dated 05.08.2003). The latter is maintained daily by a dietetic nurse.

Third group documentation. Diet service organization documentation (production documentation)

Diet service organization documentation (production documentation):

• Employee time sheet.
• Staff work schedules for a month in advance.
• A book (or folder) of orders and instructions, where instructions from higher health authorities and guidelines for the organization of therapeutic nutrition should be carefully stored in the appropriate order.
• Safety briefing log.
• Evaluation log for ready meals (rejection).
• The journal of the marriage of products and food raw materials entering the food block.
• Journal of C-vitaminization of food.
• Folder of chemical analyzes of ready meals.
• Perishable food magazine.
• Warehouse book, form No. M-17 (order of the Ministry of Health of the USSR No. 530 dated 05/05/1983).
• Administrative traversal log.
• Sanitary journal.

With the presence and proper maintenance of all documentation on the organization of the dietary service, it is possible to clearly implement the organization of medical nutrition in the institution at all stages.

The need for GOSTs

At the federal level, a number of regulatory documents in order to ensure the quality of food and the safety of their use in public catering, including treatment-and-prophylactic, in medical institutions (see tab. 2).

Federal Law of December 27, 2002 No. 184-FZ "On Technical Regulation" defined the principles of standardization in the Russian Federation, established the rules for the application of technical regulations and national standards of the Russian Federation (GOST R 1.0-2004 "Standardization in the Russian Federation. Basic Provisions"). This document states that technical regulations That is, federal laws establishing safety requirements are binding on all products.

Currently, there are technical regulations for milk and dairy products, juices and other food products.

National standards, or as they are also called, GOST R, are one of the most important components of the reform of technical regulation in the Russian Federation. They are divided into two types: standards for methods of analysis and standards that establish requirements for any type of product. The newly introduced GOST system, created to replace obsolete standards, has defined specific standards for entire product groups, including specialized ones. So, National standard of the Russian Federation GOST R 53861-2010 “Dietary (therapeutic and prophylactic) food products. Dry protein composite mixtures. General technical conditions ", approved by the order of the Federal Agency for Technical Regulation and Metrology of September 7, 2010 No. 219-st, determined the basic requirements for specialized products intended for dietary (therapeutic and prophylactic) nutrition of adults and children over three years old as a protein component for preparing ready-made meals.

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SanPiNs and regulations

A number of documents that determine the requirements for both premises, production processes, and food products are represented by sanitary rules and norms approved by the chief sanitary doctor of the Russian Federation. Here is some of them:

• Resolution of the chief state sanitary doctor RF of 05.05.2003 № 91 "On measures for the prevention of diseases caused by iron deficiency in the structure of nutrition of the population."
• Sanitary and epidemiological rules and standards SanPiN 2.3.2.1940-05 (approved by the chief state sanitary doctor on January 17, 2005, as amended on June 27, 2008) "Organization baby food", 2.3.2" Food raw materials and food products ".
• Sanitary and epidemiological rules and standards SanPiN2.3.2.1324-03 "Hygienic requirements for the shelf life and storage conditions of food".
• Resolution of the Chief State Sanitary Doctor of the Russian Federation of March 5, 2004 No. 9 "On additional measures to prevent diseases caused by micronutrient deficiency."

The implementation of these documents in the organization of preventive nutrition is also mandatory.

Federal Law of December 27, 2002 No. 184-FZ "On Technical Regulation" (adopted The State Duma December 15, 2002, approved by the Federation Council on December 18, 2002) ch. 1 " General Provisions"Art. 2. "Basic concepts":

"Technical regulations - a document that is adopted by an international treaty of the Russian Federation, subject to ratification in the manner prescribed by the legislation of the Russian Federation, or in accordance with an international treaty of the Russian Federation, ratified in the manner prescribed by the legislation of the Russian Federation, or federal law, or by decree of the President of the Russian Federation , or by a decree of the Government of the Russian Federation, or by a regulatory legal act federal body executive power for technical regulation, and establishes mandatory requirements for the application and implementation of the objects of technical regulation (products or products and related to product requirements processes of design [including survey], production, construction, installation, adjustment, operation, storage, transportation, implementation and disposal) ".

Table 2. Normative legal documents regulating the quality of food products and the safety of their use in public catering

At the level of a constituent entity of the Federation

The documents discussed in the previous sections of the article are mandatory for execution at the level of the subject of the Federation. However, when planning the organization of the therapeutic nutrition system in the region, the health authorities may issue local acts, the main criterion for which is the possibility of expanding the regulatory documents in force in the territory of the Russian Federation.

In accordance with Art. 39 of the Federal Law of the Russian Federation of November 21, 2011 No. 323-FZ "On the Fundamentals of Health Protection of Citizens in the Russian Federation" By Order of the Government of the Russian Federation No. 1873-r of October 25, 2010 "On Approval of the Fundamentals of State Policy of the Russian Federation in the Field of Healthy Nutrition of the Population for the Period until 2020 G." it was recommended that the executive authorities of the constituent entities of the Russian Federation take into account the provisions of the "Fundamentals of State Policy of the Russian Federation in the Field of Healthy Nutrition of the Population for the Period until 2020" in the formation and implementation of regional programs of socio-economic development.

Decree of the President of the Russian Federation of May 7, 2012 No. 598 "On improving the state policy in the field of health care" instructed the Government of the Russian Federation, together with the executive authorities of the constituent entities of the Russian Federation, to approve by July 1, 2012 an action plan for the implementation of the "Fundamentals of the state policy of the Russian Federation in the field of healthy nutrition. population for the period up to 2020 ".

For the implementation of the specified regulatory legal acts established by the government of the Russian Federation, as well as orders established by the Ministry of Health and Social Development of Russia, and in order to unify the requirements for the organization of dietary (therapeutic and prophylactic) nutrition, standardization of average daily food sets and a seven-day menu in medical organizations in Moscow, the Department Healthcare of the city of Moscow, Order No. 1851 of 23.12.2011 "On improving the organization of dietary (therapeutic and preventive) nutrition" was issued, as well as a number of methodological recommendations "Card file of dietary (medical and preventive) nutrition with an optimized composition for children", which regulates the algorithm for organizing dietary (therapeutic and prophylactic) nutrition in medical organizations of the city.

This order uses the norms of physical needs developed by Rospotrebnadzor (G.G. Onishchenko), the norms of protein correction of ready-made meals, calculated in accordance with the order of the Ministry of Health and Social Development of Russia No. 330. In accordance with the development of the Research Institute of Nutrition of the Russian Academy of Medical Sciences, optimized average daily sets of products are given. Thanks to the measures taken, the unification of requirements for the organization of dietary (therapeutic and prophylactic) nutrition, the standardization of average daily food sets and a seven-day menu in medical organizations in Moscow, heads of medical institutions can reasonably and effectively spend financial resources... In addition, it became necessary to introduce in the work of the health department non-departmental control over the expenditure of funds for medical nutrition and the quality of diet in medical institutions.

In some constituent entities of the Russian Federation, documents have been developed for the implementation of the main directions of the Order of the Ministry of Health of Russia dated 5.08.2003 No. 330 "On measures to improve medical nutrition in medical and preventive institutions of the Russian Federation" in accordance with the Procedure for providing medical assistance to the population on the profile "dietetics" approved by the Ministry of Health and Social Development of Russia "(See Table 3). The full texts of the documents presented in the table can be found on the website www ..

As an example of the introduction of standardization of the system of therapeutic and prophylactic nutrition, one can present an information letter from the Ministry of Health of the Territorial Fund for Compulsory Medical Insurance of the Saratov Region on September 19, 2010 No. 1103-17 / 3146, No. 4529, addressed to the heads of government bodies and health care institutions. The document is presented in the form of methodological recommendations "Standards for the organization of medical nutrition" for the organization of nutrition by clinical and statistical groups of diseases. Clinical-statistical groups include nosological forms, grouped in a set of clinical, laboratory and instrumental diagnostic signs, which made it possible to identify diseases (poisoning, trauma, physiological state) belonging to the group of conditions with a common etiology and pathogenesis, clinical manifestations, general approaches to treatment and correction (see the text of the document on the website www .. It is recommended to prescribe therapeutic nutrition to patients, depending on the following factors:

1. Clinical features of the disease:
   • clinical and statistical group of the disease;
   • stage (phase) of the disease of a particular patient;
   • a certain clinical situation;
   • existing complications of the disease.
2. Physical indicators of the ratio of the patient's weight and body, the severity of protein-energy deficiency:
   • the degree of violation of the nutritional status;
   • body mass index.
3. Individual characteristics of the organism;
   • food intolerance;
   • the presence of contraindications to the use of a number of food products in the diet;
   • the possibility of taking food products per os, the presence of a gastrostomy, enterostomy.

The process of standardization in dietetics means such actions as setting rules and characteristics for the purpose of their repeated use, aimed at achieving orderliness in the work of the catering units of medical and preventive institutions, preparing dietary meals, prescribing and choosing the type of therapeutic diet and the quality of the medical food provided to the patient.

The implementation of all stages of standardization is possible with the establishment of standards for the implementation of each specific stage of work. The use of standards allows patients to be guaranteed the safety, effectiveness, compatibility and consistency of the medical services provided to them. In general, standards should ensure compliance medical services the required level of quality requirements.

In order to form unified approaches to standardization in dietetics, it is recommended to define unified standardization objects at the level of the constituent entity of the Federation:

technologies for organizing food in medical institutions: types, production processes, food products used for a particular type of food;

• technical support for the implementation of dietary nutritional diets;
• quality of food;
• qualifications of medical personnel involved in catering;
• production, terms of sale, quality of food;
• accounting and reporting documentation used in the dietetics system;
• economic aspects of standardization, food procurement system, personalized accounting.

Table 3 . Documents on the implementation of the main directions of the order of the Ministry of Health of Russia dated 5.08.2003 No. 330

At the healthcare facility level

In medical and prophylactic institutions, the system of organizing therapeutic and prophylactic nutrition should be based on the requirements imposed at the federal level and at the level of the constituent entity of the Federation.

At the same time, when organizing medical nutrition directly in a medical institution, different kinds therapeutic nutrition (dietary, enteral and parenteral), which differ from each other in the presence of medical indications for use, organizational technologies, organization of the production process and execution technique.

Diet meals are organized and administered by a dietitian. The implementation technology is associated with the appointment of a certain diet to the patient in accordance with the approved nomenclature of diets. Organization of the work of the catering unit, the formation of food therapeutic diets (diets) for various clinical and statistical groups of patients on the basis of standard diets and special and individual diets developed on their basis with the use of food products in the preparation of dishes, including dietary products, specialized (mixtures of protein composite dry) and baby food, is the basis for the formation of a medical nutrition system in a medical institution. Protein correction of ready-made dietary meals is carried out in accordance with the requirements of the order of the Ministry of Health of the Russian Federation No. 330 and GOST R 53861-2010.

Enteral nutrition is organized and administered by a nutritional support team. In its absence, this task falls on doctors, as a rule, resuscitators with a specialization in nutritional support, and on nurses of departments who have been trained in the use of enteral mixtures (as well as other specialists involved in the process of organizing enteral nutrition). The technology for organizing and carrying out enteral nutrition is regulated in Appendix No. 5 of the instructions for organizing enteral nutrition in medical institutions (approved by order of the Ministry of Health of Russia dated 5.08.2003 No. 330) (as amended on April 26, 2006). For enteral nutrition, enteral mixtures are used, which completely replace one or more meals, are used only for medical reasons when it is impossible to adequately provide the body's energy and plastic needs in a natural way in a number of diseases. Discharge of enteral mixtures from the food warehouse is carried out on the basis of Form No. 22-MZ "Information on individual and additional nutrition" after a preliminary calculation of the patient's need for the main ingredients, filling out the observation card of a patient receiving enteral nutrition (insert in the medical card of an inpatient, registration form No. 003 / U).

The purchase of enteral mixtures is carried out in accordance with article No. 340 of the economic classification of expenditures of the budgets of the Russian Federation "Increase in the cost of inventories" with the assignment of nutritional mixtures for enteral nutrition to the section "Medicines and dressings". When carrying out full enteral nutrition, the patient should be removed from nutrition; when carrying out partial enteral nutrition, the patient should be removed from those meals that are replaced by enteral mixtures. Information about this should be entered in the patient's medical history and transferred to the catering unit.

Parenteral nutrition is organized and carried out by the nutritional support team, resuscitation doctors, as a rule, in the intensive care and intensive care units (wards). Parenteral nutritional mixtures are drugs and are classified as drug therapy. When carrying out full parenteral nutrition, the patient should be removed from nutrition. This information should be recorded in the patient's medical history.

Enteral and parenteral nutrition refers to artificial types of nutrition, which are used only for medical reasons when it is impossible to adequately meet the energy and plastic needs of the body in a natural way in a number of diseases and are presented in a number of reference books and recommendations for carrying out nutritional support in intensive care and resuscitation. These sections are not within the competence of a nutritionist, they expand the possibilities of introducing nutrients into the patient's body using alternative methods (through the vascular bed) or specially created artificial balanced nutritional mixtures, the intake of which into the human body is possible without the gastric digestion phase.

When standardizing medical nutrition, it is necessary to introduce a number of organizational standards into the work of medical institutions:

• standard of regulatory support for the implementation of federal legislation in the organization of medical nutrition in medical institutions;
• standard for the range of services and work in the organization of catering in medical institutions;
• quality standard of medical nutrition;
• the standard of prescribing therapeutic diets;
• standard of requirements for the organization of medical nutrition in inpatient medical and prophylactic institutions;
• standards for the organization of medical nutrition for various clinical and statistical groups of patients;
• standard for expert assessment of catering in health care facilities.

When organizing medical nutrition in an institution, it is necessary to determine the sequence of the main activities and distribute responsibility among the participants in this process. The most difficult role is assigned to the head of a medical and prophylactic institution. The entire subsequent process of the formation of high-quality approaches to the organization of medical nutrition depends on his actions. The list of works carried out by the head of the healthcare facility to provide food to the medical institution (organization) is presented in table. 4. The functioning of the entire system of medical nutrition in a medical institution depends on how these works and services are performed.

For the organization of effective and high-quality medical nutrition, which is part of the complex therapy of the patient, it is necessary to organize a Council for Medical Nutrition at the institution. Despite the fact that it is an advisory body, its main tasks are to control the quality of medical nutrition and the introduction of new technologies for medical nutrition. The Council for Medical Nutrition not only approves the nomenclature of diets, specialized dietary food products (mixtures of protein composite dry), mixtures for enteral nutrition, biologically active additives to be introduced in this institution, but also conducts an intradepartmental examination of the usefulness and effectiveness of medical nutrition. The Council also monitors the effectiveness of the introduction of new technologies for therapeutic nutrition.

In addition, the process of differentiated prescription of therapeutic diets must be approved by the Council for Clinical Nutrition, since the most important role in the effectiveness and quality of medical nutrition is played by the continuity between the nutrition unit and departments, the nutritionist, attending physicians and specialists involved in the treatment of patients. The practical implementation of uniform regulatory requirements for the organization of therapeutic nutrition will allow planning and formation of financing from the standpoint of rational use of financial resources.

Table 4. Work carried out by the head of the healthcare facility to provide food to the medical institution (organization)

Application of specialized products

The patient's nutrition is the basis for restoring protein losses that occur during illness, adapting to changing metabolic conditions, and also remains a fairly effective therapeutic agent and in some cases has a decisive influence on the course and outcome of the disease.

On February 3, 2005, the Ministry of Health and Social Development of Russia approved guidelines for the organization of medical nutrition in medical institutions. Currently, the so-called specialized food products have entered the composition of dietary products. Mixtures containing the main macro- and micronutrients in optimal proportions or in the amount necessary to correct the main components of food can be used as specialized products of medical nutrition in medical institutions.

Specialty health food products are specially formulated foods for sick people to enrich their diets or replace conventional foods that are medically restricted or prohibited.

Currently, in most medical institutions of the Russian Federation, the technology of protein correction of therapeutic diets has been introduced in order to increase the nutritional and biological value of diets. Nutritionists often have one of the most difficult questions in the process of practical implementation of protein correction of therapeutic diets: what specialized food products can be used for inclusion in dietary meals during protein correction? The answer to this question is quite simple: the selected products must comply with the requirements of GOST R 53861-2010, and there must be appropriate certification and quality documents for it.

A separate issue in the organization of medical nutrition is the availability in the hospital of specialized medical food products intended for the nutrition of patients with hereditary metabolic disorders (for example, with phenylketonuria or lactase deficiency). In the composition of such products, either the number of substances intolerable by the body is limited, or they are not there at all. So, with phenylketonuria, the amino acid phenylalanine is completely excluded from the diet, which is perceived by the body as a poison due to a defect in the enzyme system. That is why there are specialized health food products for children suffering from phenylketonuria, galactosemia, celiac disease.

Order of the Ministry of Health and Social Development of Russia dated 09.01.2007 No. 1 "On approval of the list of medical products and specialized medical food products ..." the List of specialized health food products for disabled children was approved. V this list Specialty health food products included:

• without phenylalanine for disabled children suffering from phenylketonuria, according to age standards;
• free of lactose and galactose for disabled children suffering from galactosemia, according to age standards;
• gluten free for disabled children with celiac disease, according to age standards.

Currently, within the framework of the Unified Sanitary Rules of the EurAsEC Customs Union, specialized food products are defined as subject to mandatory state registration, including baby food, food for pregnant and lactating women, dietary (therapeutic and prophylactic) food, food for athletes. Among the documents of the customs union that regulate the issues of specialized nutrition, it is necessary to highlight the Decision of the Commission of the Customs Union dated 28.05.2010 No. 299 "On the application of sanitary measures in the customs union", which defines a list of specialized products for medical nutrition for children.

The use of specialized food products opens great opportunities for the organization of therapeutic and prophylactic nutrition. With the help of rationally constructed diets, an increase in the general stability of the body is ensured, the use of the properties of food components, their protective effect on the structure and function of the most affected organs, compensation for excessively consumed food and biologically active substances in connection with diseases.

Federal Law of 21.11.2011 No. 323-FZ "On the Fundamentals of Health Protection of Citizens in the Russian Federation" Ch. 5 "Organization of health protection" Art. 39 "Health food":

"3. Specialized products of medical nutrition are food products with an established chemical composition, energy value and physical properties, proven therapeutic effect, which have a specific effect on the restoration of disturbed or lost body functions as a result of a disease, prevention of these disorders, as well as on increasing the adaptive capabilities of the body. "