# 381. Первичный осмотр врачом приемного отделения (дежурным врачом или лечащим врачом)

##### **Вид СЭМД 198. Актуальная версия редакции 1.**

##### **Настройки шаблона**

Для того чтобы СЭМД можно было сформировать, его необходимо настроить, <span>[согласно инструкции](https://docs.medicine-it.ru/books/instrukciia-gis-sk/page/vidy-semdov-dlia-vygruzki)</span>. СЭМД должен быть включен и настроен на необходимое число подписантов.

В осмотре необходимо настроить обязательные поля и при желании не обязательные:

<table border="1" id="bkmrk-%D0%9D%D0%B0%D0%B8%D0%BC%D0%B5%D0%BD%D0%BE%D0%B2%D0%B0%D0%BD%D0%B8%D0%B5-%D0%BF%D0%BE%D0%BB%D1%8F-%D0%A0%D0%B5" style="border-collapse: collapse; width: 100%; height: 2047.4px;"><colgroup><col style="width: 27.3373%;"></col><col style="width: 15.6196%;"></col><col style="width: 13.1378%;"></col><col style="width: 15.3846%;"></col><col style="width: 12.1893%;"></col><col style="width: 16.3314%;"></col></colgroup><tbody><tr style="height: 29.8px;"><td class="align-center" style="height: 29.8px;"><span>**Наименование поля**</span></td><td class="align-center" style="height: 29.8px;"><span>**Рег. Имя**</span></td><td class="align-center" style="height: 29.8px;"><span>**Тип поля**</span></td><td class="align-center" style="height: 29.8px;"><span>**Обязательность**</span></td><td class="align-center" style="height: 29.8px;"><span>**Справочник**</span></td><td style="height: 29.8px;"><span>**Примечание**</span></td></tr><tr style="height: 39.8px;"><td style="height: 39.8px;"><span>Общее состояние</span>

</td><td style="height: 39.8px;"><span>general\_condition</span>

</td><td style="height: 39.8px;">Справочники БД</td><td class="align-center" style="height: 39.8px;">✔</td><td style="height: 39.8px;"><span>1.2.643.5.1.13.13.11.1006</span></td><td style="height: 39.8px;"><span>  
</span></td></tr><tr style="height: 57.8px;"><td style="height: 57.8px;"><span>Объективный статус</span>

</td><td style="height: 57.8px;"><span>objective\_status</span>

</td><td style="height: 57.8px;">Текстовые поля</td><td class="align-center" style="height: 57.8px;">✔</td><td style="height: 57.8px;">  
</td><td style="height: 57.8px;">Может быть составным

</td></tr><tr style="height: 46.6px;"><td style="height: 46.6px;"><span>Диагноз</span>

</td><td style="height: 46.6px;"><span>diagnoses</span>

</td><td style="height: 46.6px;">Таблица</td><td class="align-center" style="height: 46.6px;">✔</td><td style="height: 46.6px;">  
</td><td style="height: 46.6px;">**ИЛИ** "<span>Основное заболевание МКБ"</span></td></tr><tr style="height: 57.8px;"><td style="height: 57.8px;"><span>Основное заболевание МКБ</span>

</td><td style="height: 57.8px;"><span>SEMD\_DS\_OSN\_upon\_admission</span>

</td><td style="height: 57.8px;">Справочники БД</td><td class="align-center" style="height: 57.8px;">✔</td><td style="height: 57.8px;"><span>REF\_MKB</span>

</td><td style="height: 57.8px;"><span>**ИЛИ** "Диагноз"</span>

</td></tr><tr style="height: 57.8px;"><td style="height: 57.8px;"><span>Диастолическое артериальное давление</span>

</td><td height="20" style="height: 57.8px; width: 327pt;" width="436">ad\_left\_diastolic</td><td style="height: 57.8px;">Дробное число</td><td style="height: 57.8px;">  
</td><td style="height: 57.8px;"><span>  
</span>

</td><td style="height: 57.8px;"><span>  
</span>

</td></tr><tr style="height: 57.8px;"><td style="height: 57.8px;"><span>Систолическое артериальное давление</span>

</td><td height="20" style="height: 57.8px;">ad\_left\_systolic</td><td style="height: 57.8px;">Дробное число</td><td style="height: 57.8px;">  
</td><td style="height: 57.8px;"><span>  
</span>

</td><td style="height: 57.8px;"><span>  
</span>

</td></tr><tr style="height: 46.6px;"><td style="height: 46.6px;"><span>Дополнительно</span>

</td><td height="20" style="height: 46.6px;">additionally</td><td style="height: 46.6px;">Текстовые поля</td><td style="height: 46.6px;">  
</td><td style="height: 46.6px;"><span>  
</span>

</td><td style="height: 46.6px;"><span>  
</span>

</td></tr><tr style="height: 46.6px;"><td style="height: 46.6px;"><span>Анамнез заболевания</span>

</td><td height="20" style="height: 46.6px;">anamnesis\_morbi</td><td style="height: 46.6px;">Текстовые поля</td><td style="height: 46.6px;">  
</td><td style="height: 46.6px;"><span>  
</span>

</td><td style="height: 46.6px;"><span>  
</span>

</td></tr><tr style="height: 46.6px;"><td style="height: 46.6px;"><span>Анамнез жизни</span>

</td><td height="20" style="height: 46.6px;">anamnesis\_vitae</td><td style="height: 46.6px;">Текстовые поля</td><td style="height: 46.6px;">  
</td><td style="height: 46.6px;"><span>  
</span>

</td><td style="height: 46.6px;"><span>  
</span>

</td></tr><tr style="height: 46.6px;"><td style="height: 46.6px;"><span>Индекс Массы Тела</span>

</td><td height="20" style="height: 46.6px;">body\_mass\_index</td><td style="height: 46.6px;">Дробное число</td><td style="height: 46.6px;">  
</td><td style="height: 46.6px;"><span>  
</span>

</td><td style="height: 46.6px;"><span>  
</span>

</td></tr><tr style="height: 46.6px;"><td style="height: 46.6px;"><span>Температура тела</span>

</td><td height="20" style="height: 46.6px;">body\_temperature</td><td style="height: 46.6px;">Дробное число</td><td style="height: 46.6px;">  
</td><td style="height: 46.6px;"><span>  
</span>

</td><td style="height: 46.6px;"><span>  
</span>

</td></tr><tr style="height: 57.8px;"><td style="height: 57.8px;"><span>Тип телосложения</span>

</td><td height="20" style="height: 57.8px;">body\_type</td><td style="height: 57.8px;">Справочники БД</td><td style="height: 57.8px;">  
</td><td style="height: 57.8px;"><span>1.2.643.5.1.13.13.11.1492</span>

</td><td style="height: 57.8px;"><span>  
</span>

</td></tr><tr style="height: 46.6px;"><td style="height: 46.6px;"><span>Масса тела</span>

</td><td height="20" style="height: 46.6px;">body\_weight</td><td style="height: 46.6px;">Дробное число</td><td style="height: 46.6px;">  
</td><td style="height: 46.6px;"><span>  
</span>

</td><td style="height: 46.6px;"><span>  
</span>

</td></tr><tr style="height: 57.8px;"><td style="height: 57.8px;"><span>Циркуляционная система</span>

</td><td height="20" style="height: 57.8px;">circulatory\_system</td><td style="height: 57.8px;">Текстовые поля</td><td style="height: 57.8px;">  
</td><td style="height: 57.8px;"><span>  
</span>

</td><td style="height: 57.8px;"><span>  
</span>

</td></tr><tr style="height: 46.6px;"><td style="height: 46.6px;"><span>Жалобы пациента</span>

</td><td height="20" style="height: 46.6px;">complaints</td><td style="height: 46.6px;">Текстовые поля</td><td style="height: 46.6px;">  
</td><td style="height: 46.6px;"><span>  
</span>

</td><td style="height: 46.6px;"><span>  
</span>

</td></tr><tr style="height: 46.6px;"><td style="height: 46.6px;">Основное заболевание при поступлении</td><td height="20" style="height: 46.6px;">conclusion\_upon\_admission</td><td style="height: 46.6px;">Текстовые поля</td><td style="height: 46.6px;">  
</td><td style="height: 46.6px;">  
</td><td style="height: 46.6px;">  
</td></tr><tr style="height: 29.8px;"><td style="height: 29.8px;">Данные мс</td><td height="20" style="height: 29.8px;">danie\_ms</td><td style="height: 29.8px;">Таблица</td><td style="height: 29.8px;">  
</td><td style="height: 29.8px;">  
</td><td style="height: 29.8px;">  
</td></tr><tr style="height: 46.6px;"><td style="height: 46.6px;">Пищеварительная система</td><td height="20" style="height: 46.6px;">digestive\_system</td><td style="height: 46.6px;">Текстовые поля</td><td style="height: 46.6px;">  
</td><td style="height: 46.6px;">  
</td><td style="height: 46.6px;">  
</td></tr><tr style="height: 46.6px;"><td style="height: 46.6px;">Частая дефекация</td><td height="20" style="height: 46.6px;">frequency\_defecation</td><td style="height: 46.6px;">Дробное число</td><td style="height: 46.6px;">  
</td><td style="height: 46.6px;">  
</td><td style="height: 46.6px;">  
</td></tr><tr style="height: 46.6px;"><td style="height: 46.6px;">Мочеполовая система</td><td height="20" style="height: 46.6px;">genitourinary\_system</td><td style="height: 46.6px;">Текстовые поля</td><td style="height: 46.6px;">  
</td><td style="height: 46.6px;">  
</td><td style="height: 46.6px;">  
</td></tr><tr style="height: 46.6px;"><td style="height: 46.6px;">Рост

</td><td height="20" style="height: 46.6px;">height</td><td style="height: 46.6px;">Дробное число</td><td style="height: 46.6px;">  
</td><td style="height: 46.6px;">  
</td><td style="height: 46.6px;">  
</td></tr><tr style="height: 46.6px;"><td style="height: 46.6px;">Обоснование диагноза</td><td height="20" style="height: 46.6px;">justification</td><td style="height: 46.6px;">Текстовые поля</td><td style="height: 46.6px;">  
</td><td style="height: 46.6px;">  
</td><td style="height: 46.6px;">  
</td></tr><tr style="height: 46.6px;"><td style="height: 46.6px;">Асимметричность / Латеральность</td><td height="20" style="height: 46.6px;">laterality</td><td style="height: 46.6px;">Справочники БД</td><td style="height: 46.6px;">  
</td><td style="height: 46.6px;">1.2.643.5.1.13.13.99.2.778  
</td><td style="height: 46.6px;">  
</td></tr><tr style="height: 46.6px;"><td style="height: 46.6px;">Медицинские вмешательства

</td><td height="20" style="height: 46.6px;">medical\_interventions</td><td style="height: 46.6px;">Текстовые поля</td><td style="height: 46.6px;">  
</td><td style="height: 46.6px;">  
</td><td style="height: 46.6px;">  
</td></tr><tr style="height: 46.6px;"><td style="height: 46.6px;">Психическое состояние</td><td height="20" style="height: 46.6px;">mental\_status</td><td style="height: 46.6px;">Текстовые поля</td><td style="height: 46.6px;">  
</td><td style="height: 46.6px;">  
</td><td style="height: 46.6px;">  
</td></tr><tr style="height: 46.6px;"><td style="height: 46.6px;">Опорно-двигательный аппарат</td><td height="20" style="height: 46.6px;">musculoskeletal\_system</td><td style="height: 46.6px;">Текстовые поля</td><td style="height: 46.6px;">  
</td><td style="height: 46.6px;">  
</td><td style="height: 46.6px;">  
</td></tr><tr style="height: 46.6px;"><td style="height: 46.6px;">  
</td><td height="20" style="height: 46.6px;">ne\_lec</td><td style="height: 46.6px;">Текстовые поля</td><td style="height: 46.6px;">  
</td><td style="height: 46.6px;">  
</td><td style="height: 46.6px;">  
</td></tr><tr style="height: 46.6px;"><td style="height: 46.6px;">Нервная система</td><td height="20" style="height: 46.6px;">nervous\_system</td><td style="height: 46.6px;">Текстовые поля</td><td style="height: 46.6px;">  
</td><td style="height: 46.6px;">  
</td><td style="height: 46.6px;">  
</td></tr><tr style="height: 46.6px;"><td style="height: 46.6px;">Патологии</td><td height="20" style="height: 46.6px;">pathologies</td><td style="height: 46.6px;">Справочники БД</td><td style="height: 46.6px;">  
</td><td style="height: 46.6px;">1.2.643.5.1.13.13.11.1473</td><td style="height: 46.6px;">  
</td></tr><tr style="height: 46.6px;"><td style="height: 46.6px;">Лекарственный план</td><td height="20" style="height: 46.6px;">plan\_lec</td><td style="height: 46.6px;">Текстовые поля</td><td style="height: 46.6px;">  
</td><td style="height: 46.6px;">  
</td><td style="height: 46.6px;">  
</td></tr><tr style="height: 46.6px;"><td style="height: 46.6px;">План обследования</td><td height="20" style="height: 46.6px;">plan\_obsled</td><td style="height: 46.6px;">Текстовые поля</td><td style="height: 46.6px;">  
</td><td style="height: 46.6px;">  
</td><td style="height: 46.6px;">  
</td></tr><tr style="height: 46.6px;"><td style="height: 46.6px;">Пульс</td><td height="20" style="height: 46.6px;">pulse</td><td style="height: 46.6px;">Дробное число</td><td style="height: 46.6px;">  
</td><td style="height: 46.6px;">  
</td><td style="height: 46.6px;">  
</td></tr><tr style="height: 46.6px;"><td style="height: 46.6px;">Органы дыхания</td><td height="20" style="height: 46.6px;">respiratory\_organs</td><td style="height: 46.6px;">Текстовые поля</td><td style="height: 46.6px;">  
</td><td style="height: 46.6px;">  
</td><td style="height: 46.6px;">  
</td></tr><tr style="height: 46.6px;"><td style="height: 46.6px;">ЧДД</td><td height="20" style="height: 46.6px;">respiratory\_rate</td><td style="height: 46.6px;">Дробное число</td><td style="height: 46.6px;">  
</td><td style="height: 46.6px;">  
</td><td style="height: 46.6px;">  
</td></tr><tr style="height: 46.6px;"><td style="height: 46.6px;">Сатурация (SpO2)</td><td height="20" style="height: 46.6px;">saturation</td><td style="height: 46.6px;">Дробное число</td><td style="height: 46.6px;">  
</td><td style="height: 46.6px;">  
</td><td style="height: 46.6px;">  
</td></tr><tr style="height: 63.4px;"><td style="height: 63.4px;">Сопутствующие заболевания при поступлении</td><td height="20" style="height: 63.4px;">SEMD\_DS\_DOP\_TXT\_upon\_admission</td><td style="height: 63.4px;">Текстовые поля</td><td style="height: 63.4px;">  
</td><td style="height: 63.4px;">  
</td><td style="height: 63.4px;">  
</td></tr><tr style="height: 46.6px;"><td style="height: 46.6px;">Сопутствующие заболевания при поступлении (МКБ)</td><td height="20" style="height: 46.6px;">SEMD\_DS\_DOP\_upon\_admission</td><td style="height: 46.6px;">Справочники БД</td><td style="height: 46.6px;">  
</td><td style="height: 46.6px;"><span>REF\_MKB</span></td><td style="height: 46.6px;">  
</td></tr><tr style="height: 46.6px;"><td style="height: 46.6px;">Осложнения основного заболевания при поступлении</td><td height="20" style="height: 46.6px;">SEMD\_DS\_OSL\_TXT\_upon\_admission</td><td style="height: 46.6px;">Текстовые поля</td><td style="height: 46.6px;">  
</td><td style="height: 46.6px;">  
</td><td style="height: 46.6px;">  
</td></tr><tr style="height: 63.4px;"><td style="height: 63.4px;">Осложнения основного заболевания при поступлении (МКБ)</td><td height="20" style="height: 63.4px;">SEMD\_DS\_OSL\_upon\_admission</td><td style="height: 63.4px;">Справочники БД</td><td style="height: 63.4px;">  
</td><td style="height: 63.4px;"><span>REF\_MKB</span></td><td style="height: 63.4px;">  
</td></tr><tr style="height: 29.8px;"><td style="height: 29.8px;">Шкала в виде таблицы</td><td height="20" style="height: 29.8px;">shkala\_tabl</td><td style="height: 29.8px;">Таблица</td><td style="height: 29.8px;">  
</td><td style="height: 29.8px;">  
</td><td style="height: 29.8px;">  
</td></tr><tr style="height: 46.6px;"><td style="height: 46.6px;">Кожа</td><td height="20" style="height: 46.6px;">skin</td><td style="height: 46.6px;">Текстовые поля</td><td style="height: 46.6px;">  
</td><td style="height: 46.6px;">  
</td><td style="height: 46.6px;">  
</td></tr><tr style="height: 46.6px;"><td style="height: 46.6px;">Локальный статус</td><td height="20" style="height: 46.6px;">status\_localis</td><td style="height: 46.6px;">Текстовые поля</td><td style="height: 46.6px;">  
</td><td style="height: 46.6px;">  
</td><td style="height: 46.6px;">  
</td></tr></tbody></table>

В случаи использования таблицы необходимо:

<table border="1" id="bkmrk-%D0%9D%D0%B0%D0%B8%D0%BC%D0%B5%D0%BD%D0%BE%D0%B2%D0%B0%D0%BD%D0%B8%D0%B5-%D0%BA%D0%BE%D0%BB%D0%BE%D0%BD%D0%BA%D0%B8" style="border-collapse: collapse; width: 100%; height: 119.2px;"><colgroup><col style="width: 29.5825%;"></col><col style="width: 26.865%;"></col><col style="width: 15.384%;"></col><col style="width: 28.2829%;"></col></colgroup><tbody><tr style="height: 29.8px;"><td class="align-center" style="height: 29.8px;">**Наименование колонки**</td><td class="align-center" style="height: 29.8px;">**Тип поля**</td><td class="align-center">**<span>Обязательность</span>**</td><td class="align-center" style="height: 29.8px;">**Примечание**</td></tr><tr style="height: 29.8px;"><td style="height: 29.8px;">МКБ-10</td><td style="height: 29.8px;">Справочники БД</td><td class="align-center">✔</td><td style="height: 29.8px;"><span>REF\_MKB</span></td></tr><tr style="height: 29.8px;"><td style="height: 29.8px;">Клинический диагноз</td><td style="height: 29.8px;">Текстовые поля</td><td class="align-center">  
</td><td style="height: 29.8px;">  
</td></tr><tr style="height: 29.8px;"><td style="height: 29.8px;">Тип</td><td style="height: 29.8px;">Справочники БД</td><td class="align-center">✔</td><td style="height: 29.8px;">1.2.643.5.1.13.13.11.1077</td></tr></tbody></table>

##### **Схема настройки и формирования СЭМДа**

<span>![](https://docs.medicine-it.ru/uploads/images/gallery/2026-08/embedded-image-wyusghzl.png)</span>