Program center "assistance to education". Regulatory legal documents Order 330 on clinical nutrition with changes

Act for the destruction of used ampoules from narcotic drugs and psychotropic substances (Appendix 10). (As amended by the Order of the Ministry of Health of the Russian Federation dated May 16, 2003 N 205)

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

2.2. Heads of health authorities and pharmaceutical organizations in the constituent entities of the Russian Federation:

2.1. To impose on the heads of medical and preventive institutions personal responsibility for accounting, safety, 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 dated May 16, 2003 N 205)

2.2. Provide medical and preventive 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 the health authorities and medical and preventive institutions should not exceed the monthly requirement. (As amended by the Order of the Ministry of Health of the Russian Federation dated May 16, 2003 N 205)

2.3. Oblige the heads of medical and preventive institutions (or their deputies) to ensure that special prescription forms for narcotic drugs are stored only in a safe, the key to which must be kept by these heads; and exercise systematic control over the prescription of narcotic drugs and psychotropic substances and the established procedure for their prescribing (Appendix 2). To categorically prohibit doctors from issuing and also 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 dated May 16, 2003 N 205)

2.4. To oblige attending physicians to prescribe and use narcotic drugs and psychotropic substances, regardless of the dosage form, with entries in the medical history and prescription sheet indicating the name of the dosage form of the narcotic drug and psychotropic substance, its quantity and dosage. (As amended by the Order of the Ministry of Health of the Russian Federation dated May 16, 2003 N 205)

2.5. To oblige attending physicians or doctors on duty to hand over used ampoules from narcotic drugs and psychotropic substances on the same day, except for weekends and public holidays, deputy head of 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 relevant act in the prescribed form (Appendix 10). (As amended by the Order of the Ministry of Health of the Russian Federation dated May 16, 2003 N 205)

3. The Standing Committee on Drug Control, heads of medical and preventive institutions, heads of scientific - research institutions when determining the need for narcotic drugs and psychotropic substances, be guided by the norms for the consumption of narcotic drugs and psychotropic substances (Tables 2 and 3). (As amended by the Order of the Ministry of Health of the Russian Federation dated May 16, 2003 N 205)

4. Heads of 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 and psychotropic substances in pharmacies and medical - preventive institutions. In case of revealing facts of violation of the procedure for appointing and admitting persons to work with narcotic drugs and psychotropic substances, the perpetrators shall be 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 dated May 16, 2003 N 205)

5. Heads of health authorities and pharmaceutical organizations in the constituent entities of the Russian Federation to bring this Order to the attention of medical and pharmaceutical workers to constantly monitor its implementation.

6. To consider as not valid on the territory of the Russian Federation Order of the Ministry of Health of the USSR of December 30, 1982 N 1311 "On measures to eliminate serious shortcomings and further strengthen the fight against drug addiction, improve accounting, storage, prescription and use of narcotic drugs and psychotropic substances" (Appendix 2 "Form of a special prescription form for a narcotic drug and a psychotropic substance", Appendix 3 "Consumption rates for 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 preventive 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 pharmacy departments", Appendix 9 "Rules for the storage and accounting of narcotic drugs in research institutes, laboratories and educational institutions 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 on the destruction of used ampoules from narcotic drugs and psychotropic substances in healthcare institutions"). (As amended by the Order of the Ministry of Health of the Russian Federation dated May 16, 2003 N 205)

7. To impose control over the implementation of this Order on the Deputy Minister of Health Vilken A.E.

Minister
T.B. DMITRIEV

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

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

APPENDIX 1. TYPICAL REQUIREMENTS FOR TECHNICAL STRENGTHENING AND EQUIPMENT WITH MEANS OF SECURITY AND FIRE ALARM IN PREMISES WITH STORAGE OF NARCOTIC DRUGS - No longer valid. dated 11/17/2010 N 1008n)

Annex 2
APPROVED
Order of the Ministry
health care
Russian Federation
dated November 12, 1997 N 330

APPENDIX 2. FORM OF SPECIAL PRECISION FORM FOR 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 dated November 17, 2010 N 1008n)

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

dated 01/09/2001 N 2, dated 05/16/2003 N 205)

Table 1

ESTIMATED STANDARDS FOR THE NEED FOR NARCOTIC DRUGS AND PSYCHOTROPIC SUBSTANCES PER 1000 POPULATION PER YEAR (IN GRAM)

(As amended by the Order of the Ministry of Health of the Russian Federation dated May 16, 2003 N 205)

N p / p	Name of medicines	Norm per 1000 people
1.	Morphine hydrochloride	0,3
2.	Promedol (trimeperidine)	5,0
3.	Omnopon	0,3
4.	Cocaine	0,02
5.	Dionine (ethylmorphine)	0,1
6.	Estocin hydrochloride	0,3
7.	Codeine	70,3
8.	Opium	833,3
9.	Fentanyl	0,006

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, all dosage forms containing these substances should be recalculated for a purely active drug.

Chairman
Standing Committee
drug control
E.A. BABAYAN

table 2

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

(As amended by the Order of the Ministry of Health of the Russian Federation dated May 16, 2003 N 205)

N p / p	Name of the medical facility	Name of the narcotic drug and psychotropic substance<**>
		morphine hydrochloride 1% (amp)	omnopon 1% - 1.0 (amp)	omnopon 2% - 1.0 (amp)	promedol 1% - 1.0 (amp)	promedol 2% - 1.0 (amp)	morphine-like total (amp)	fentanyl 0.005 2%<*>(amp)	promedol (gr)	promedol in the table. (pack)	estocin in the table. 0.015 (pack)	ethylmorphine hydrochloride (gr)	codeine and its salts (gr)	codeine cough tablets (pack)	cocaine hydrochloride (gr)
1	2	3	4	5	6	7	8	9	10	11	12	13	14	15	16
1	Therapeutic	3,0	0,5	2,0	0,5	5,0	11,0	0,4	0,25	1,5	0,6	0,5	0,2	5,0
2	Gastroenterological	3,0		0,5	0,5	5,5	9,5	1,0		0,5				2
3	Cardiology	1,0	0,5	1,5	0,5	5,5	9,0	1,5		1,0		2,0		1,0
4	Pulmonary	1,0	1,0	2,0	1,0	6,0	11,0	0,5				0,06	0,2	4,0
5	Allergological					1,0	1,0							1,0
6	Endocrinological			0,6		1,0	1,6	3,0				0,01		0,1
7	Nephrological	3,0		0,5	0,5	5,5	9,5	1,0		0,5				1,5
8	Hematological	2,5	2,0	12,0	4,0	36,0	56,5	5,0		0,5		0,3		1,5
9	Occupational pathology	1,0	1,0	2,0	0,5	6,0	10,0					0,06	0,2	3,0
10	Surgical	6,0	1,5	8,5	7,0	58,0	81,0	6,0	0,4	1,0	0,2	0,4	0,3	6,0	0,04
11	Traumatological	3,0	1,0	5,0	3,0	21,0	33,0	2,0		0,5		0,5		3,0	0,03
12	Orthopedic			0,2	1,0	4,0	5,2
13	Urological	5,0	0,5	5,0	4,0	31,0	45,0	7,0	0,3			0,07	0,2	3,0
14	Thoracic Surgery	2,0		5,0	20,0	150,5	177,0	5,0			0,2			5,0
15	Burn	9,5	3,0	13,0	15,0	115,0	155,5	11,0	0,6	4,0	0,2	0,3	0,5	5,0	0,5
16	resuscitation	9,0	1,0	10,0	20,0	145,0	185,0	100,0
17	infectious	2,0	3,0	2,0	31,0	5,0	43,0	0,2		1,0		0,3		7,5
18	For pregnant women and women in childbirth	4,0	0,5	1,0	6,0	4,0	15,5	1,0		1,0		0,25		1,0
19	Pathologies of pregnant women					0,5	0,5							0,1
20	Gynecological	3,0	2,5	9,0	2,5	14,0	31,0	4,0		7,0	0,9	0,05		1,5
21	neurological	0,5		0,5	2,0	1,0	4,0	0,6	0,3			0,45	0,6	1,5	0,03
22	Psychiatric	0,2				0,2	0,4					0,15	0,4	0,1
23	Ophthalmic	0,3	0,5	0,5	0,5	4,0	5,8	1,0	0,3		0,2	0,7		1,5	0,2
24	Otolaryngological	2,0		6,0	0,5	3,5	12,0	0,6	0,3			1,3		2,5	3,0
25	Dermatovenerological					0,1	0,1					0,1		4,0
26	tuberculosis	2,0		1,5	1,0	2,0	6,5		0,1	1,2	0,2	0,35		4,0	0,01
27	Narcological													0,1
28	Pediatric	0,2	0,1		0,3		0,3			1,2		0,05	1,0	1,0
29	Oncological	2,5		15,5	2,0	60,0	80,0	10,0		0,5		0,4		1,7
30	Radioradiological	0,5	2,5	12,0	3,0	7,0	26,0	1,0		0,1
31	reception			0,1		0,25	0,38							0,45
32	In a rural district hospital, including an outpatient appointment	10,0	1,0	6,0	2,0	7,0	26,0	20,0	0,2	0,2		0,2	0,5	6,0	0,1
33	Polyclinic and outpatient clinic	2,0	0,7	0,3	1,0	2,0	6,0			0,5		0,2		2,0	0,04
34	Dental clinic		0,2	0,3	0,3/ 0,3	- / 0,5	0,35/ 0,85	- / 1,0							0,2
35	Oncology Center	140			55,0	80,0	275,0
36	Tuberculosis dispensary			1,0	0,5	1,0	3,0							3,5
37	For 1000 cases of emergency medical care. help	14,0		7,0		39,0	60,0	2,5		1,5

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

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

Notes:

1) The heads of the health authorities of the constituent entities of the Russian Federation are allowed, on the proposals of the heads of medical and preventive institutions, to increase the calculation 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 preventive institutions are allowed to redistribute between the departments the narcotic drugs and psychotropic substances indicated in this table within the limits of the general requirement standard for the institution for each item. (As amended by the Orders of the Ministry of Health of the Russian Federation dated 01/09/2001 N 2, dated 05/16/2003 N 205)

3) If there are medical indications for the relief of severe pain 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 dated 01/09/2001 N 2, dated 05/16/2003 N 205)

Chairman
Standing Committee
drug control
E.A. BABAYAN

Table 3

CALCULATION STANDARDS
REQUIREMENTS FOR NARCOTIC DRUGS AND PSYCHOTROPIC SUBSTANCES PER BED PER YEAR FOR THE ONCOLOGICAL DEPARTMENT (WARD) OF PALLIATIVE CARE IN THE MEDICAL AND PREVENTIVE INSTITUTION AND HOSPICE

(As amended by the Orders of the Ministry of Health of the Russian Federation dated 01/09/2001 N 2, dated 05/16/2003 N 205)

N p / p	Name medicinal product	Release form and dosage	Quantity
1	2	3	4
1.	Buprenorphine	Sublingual tablets 0.2 mg	157.5 tab.
		Injection,
		ampoules 0.3 mg in 1 ml	105 ampoules
		ampoules 0.6 mg in 1 ml	52.5 amp. in total<*>- 94.5 mg
2.	Dihydrocodeine - retard	Tablets for oral administration
		60 mg	158.7 tab.
		90 mg	105.8 tab.
		120 mg	79.3 tab. in total<*>- 28.56 gr.
3.	Dipidolor (pyritramide)	Solution for injection, ampoules 0.75%, 2 ml	210 amp.
4.	Morphine sulfate (MCT continus or other analogues with a duration of action of at least 12 hours)	Extended-release tablets for oral administration
		10 mg	120 tab.
		30 mg	40 tab.
		60 mg	20 tab.
		100 mg	12 tab.
		200 mg	16 tab. in total<*>- 6.0 gr.
5.	Morphine hydrochloride	Tablets for oral administration
		10 mg	63 tab.
			63 ampoules in total<*>- 1.26 gr.
6.	Omnopon	Injection,
		ampoules 1%, 1 ml	60 ampoules
		ampoules 2%, 1 ml	30 ampoules in total<*>- 1.2 gr.
7.	Promedol (trimeperidine hydrochloride)	Injection,
		ampoules 1%, 1 ml	40 ampoules
		ampoules 2%, 1 ml	20 ampoules
		Tablets for oral administration
		25 mg	126 tab. in total<*>- 4.95 gr.
8.	Prosidol	Tablets for literal intake
		10 mg	765 tab.
		20 mg	382.5 tab.
		25 mg	306 tab.
		Solution for injection, ampoules 10 mg in 1 ml	191.3 amp. in total<*>- 24.86 gr.
9.	Fentanyl - transdermal dosage form	Patch
		25 mcg/hour	7.5 layer.
		50 mcg/hour	3.75 layer.
		75 mcg/hour	2.5 layer.
		100 mcg/hour	1.9 layer.
			For medicinal purposes, the patch is not subject to crushing in total<*>- 750 mcg/hour

<*>In terms of pure active substance.

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

Chairman
Standing Committee
drug control
E.A. BABAYAN

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

Appendix 4
APPROVED
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 - No longer valid. (As amended by the Order of the Ministry of Health and Social Development of the Russian Federation dated November 17, 2010 N 1008n)

APPROVED
Order of the Ministry
health care
Russian Federation
dated November 12, 1997 N 330

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 November 21, 2011 No. 323-FZ “On the Fundamentals of Protecting the Health of Citizens in the Russian Federation” defines the rules governing the basics of the organization of clinical nutrition.

• Table 3. Documents on the implementation of the main directions of the order of the Ministry of Health of Russia dated August 5, 2003 No. 330

Organization of medical nutrition at the federal level

Organization of medical nutrition federal level takes place in accordance with the requirements of the following regulations:

Federal Law No. 323-FZ dated November 21, 2011 “On the Fundamentals of Protecting the Health 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, guidelines 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 Providing medical care the population in the field of "dietology". The order is a regulatory document that defines the principles, procedure and system for organizing medical nutrition in the Russian Federation.

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

Regulatory documents, the names of which are presented in Table. 1, are currently valid throughout our country and are mandatory for medical organizations when organizing medical nutrition.

The organization of therapeutic and prophylactic nutrition of patients undergoing inpatient treatment must be carried out in all medical organizations, with round-the-clock beds and day-stay beds with meals, sanatoriums in accordance with Order of the Ministry of Health of Russia dated August 5, 2003 No. 330 “On measures to improve clinical nutrition in medical institutions of the Russian Federation”.

The documents approved by this order are mandatory for use in organizing the nutrition system, document flow, accounting for food consumption, prescribing therapeutic 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 therapeutic nutrition in medical institutions. It defines the following standards for the organization of therapeutic nutrition:

• Characteristics, chemical composition and energy value of standard diets used in healthcare facilities (hospitals, etc.).
• Ratio natural products nutrition and specialized food products in the daily diet of the patient.
• Interchangeability of products in the preparation of dietary dishes.
• Replacement of products for proteins and carbohydrates.
• The procedure for extracting food for patients in medical institutions.
• The procedure for monitoring the quality of prepared food in a medical institution.
• Recommendations for the equipment of the catering unit and pantry.
• Transportation of prepared food.
• Sanitary and hygienic regime of the catering unit and pantry.
• The list of documentation of the catering department for the discharge of foodresearch and control over the quality of prepared food in medical institutions.

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

Instructions for the organization of enteral nutrition in medical institutions are also mandatory. In order to standardize the delivery 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 malnutrition;
• observation card of a patient receiving enteral nutrition (insert in the medical record of an inpatient, registration form 003/U);
• methodology for determining the energy needs of the body;
• the choice 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 certain diseases;
• ways of introducing enteral nutritional mixtures.

Federal Departmental Order of the Ministry of Health of the USSR dated May 5, 1983 No. 530 “On approval of instructions for accounting for food products in medical and preventive and other health care institutions that are on the state budget of the USSR”(as amended on 05/17/1984, 12/30/1987) and Order of the Ministry of Health of Russia dated 08/05/2003 No. 330 "On measures to improve therapeutic nutrition in medical institutions of the Russian Federation" approved the accounting and document management system. It is necessary to maintain documentation in accordance with the requirements of these orders, since it is not only a system for recording patients put on food, but also a system for spending food, controlling the spending of financial resources.

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

1. Documentation intended for the issuance of food products and accounting, appropriations issued for them.
2. Documents reflecting the control over the health status of catering employees.
3. Documentation on the organization of a dietary service (production documentation).

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

"On the basics of protecting the health of citizens in the Russian Federation", Ch. 5 "Organization of health care" Art. 39 "Healing nutrition":

"one. Therapeutic nutrition is nutrition that ensures the satisfaction of the physiological needs of the human body in nutrients and energy, taking into account the mechanisms of the development of the disease, the characteristics of the course of the underlying and concomitant diseases, and performing preventive and therapeutic tasks.

Federal Law of November 21, 2011 No. 323-FZ “On the Fundamentals of Protecting the Health of Citizens in the Russian Federation”, Ch. 5 "Organization of health care" Art. 39 "Healthy nutrition": "Norms of medical nutrition are approved by the authorized federal executive body."

Table 1. Regulatory documents that are mandatory for implementation by medical organizations in the organization of medical nutrition

Legal document	Nutritional norms
Order of the Ministry of Health of Russia dated August 5, 2003 No. 330 “On measures to improve clinical nutrition in medical institutions of the Russian Federation” (registered in the Ministry of Justice of Russia on September 12, 2003 No. 5073) as amended by orders of the Ministry of Health and Social Development of Russia dated October 7, 2005 No. 624 (registered with the Ministry of Justice of Russia on November 1, 2005 No. 7134), dated January 10, 2006 No. 2 (registered with the Ministry of Justice of the Russian Federation on January 24, 2006 No. 7411) and dated April 26, 2006 No. 316 (registered in the Ministry of Justice of Russia on May 26, 2006 No. 7878).	The average daily set of products per patient in medical institutions. Average daily food packages for children undergoing treatment in sanatorium-and-spa institutions of various profiles (except for tuberculosis). The average daily set of products for adults undergoing sanatorium treatment. Average daily food packages for children affected by radiation exposure, who are being treated in sanatorium-and-spa institutions of various profiles (except for tuberculosis).
Order of the Ministry of Health of the USSR No. 333 of March 10, 1986 “On Improving the Organization of Medical Nutrition in Maternity Hospitals (Departments) and Children's Hospitals (Departments)”. The text of the order has not been officially published. The specified nutritional norms for patients were agreed with the USSR Ministry of Finance (letter of the USSR Ministry of Finance dated September 12, 1985 No. 23-2-10/11).	Nutritional norm for patients in maternity hospitals (departments) and children's hospitals (departments) per patient per day in grams.
Order of the Ministry of Health and Medical Industry of the Russian Federation of May 6, 1995 No. 122 “On measures to improve the operation of hospitals for war veterans”. The text of the order has not been officially published.	The average daily set of food products for patients undergoing treatment in hospitals (departments of general hospitals) for war veterans.
Orders of the Ministry of Health of the USSR dated May 5, 1983 No. 530 “On approval of the instructions for accounting for food products in medical and preventive and other health care institutions that are on the state budget of the USSR” (as amended on May 17, 1984, December 30, 1987).	Unified food accounting system in a medical institution.

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

The main reporting forms, which are compiled to provide food for patients admitted to the hospital, belong to the documents of the first group.

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

Seven Day Consolidated Menu

Based on the card index, a seven-day summary menu is compiled. Using the seven-day menu in the work, it is possible to plan the volume of food purchases, organize the work of the catering staff, and develop standards in the preparation of various dishes.

It is recommended to have two menus - autumn-summer and winter-spring, since the assortment of products changes depending on the time of year, in addition, some products have a 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 for Clinical Nutrition.

The number of diets and their set should be individual for each institution and adapted to its profile. When compiling the menu, it is very important to take into account the qualitative variety of dishes during the day and the 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 diets, their energy value, the correct use of natural food norms, the consumption of appropriations allocated 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 relevant 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 stored in the accounting department, and the second - at nurse dietary.

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

Diet nomenclature

Standard diets- these 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 products used as the main therapeutic diets, as well as the cooking technologies used.

Special diets are assigned to a specific clinical and statistical group of patients, the condition of which requires exclusion from the therapeutic diet of certain food products, 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 foods from the diet. If he has a decrease in body mass index below the standard values, 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 mandatory manner in a medical institution refer to accounting and reporting documents. In medical institutions, in order to optimize work, they are currently introducing automated systems workflow, which ensure the implementation of evidence-based principles of nutrition.

Information about the presence of patients who are on meals, are submitted in the form of form No. 22 in accordance with order No. 330 of 05.08.2003. This form is the basis for planning and distributing patients according to diets and meals.

Basic legal document, on the basis of which food products are issued from the warehouse to the food unit for cooking and appropriations for food are spent, this layout menu(form No. 44-MZ, order No. 330 dated 05.08.2003). The last digit in the layout menu is entered by an accounting worker who calculates total all products necessary for the preparation of all 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 made in two copies. One copy remains after the issuance 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 daily supply pantry. For them full liability is carried out by the head of production (chef). The next day, he distributes food to the chefs 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.

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

If the number of patients changes compared to the menu layout data (or menu requirements) by more than three people, the dietary nurse prepares "Information on the movement of patients". In accordance with this document, it draws up 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 compared to the previous day, then the products not used for cooking are returned to the warehouse in the same form with the indication “Return” (except for the products already put into the boiler when preparing breakfast).

Form No. 23-MZ "Distribution list for vacation to food ration departments"(meal: breakfast, lunch, dinner, etc.). This document serves as the basis for issuing ready-made meals to hospital departments.

The menu is recommended to be posted at the entrance to the dining room so that patients can familiarize themselves with it. Responsible for the organization of clinical 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 for the past month. The accountant must prepare it by the 10th day of the next month and submit it to a dietitian or a person responsible for organizing clinical nutrition for analysis of the fulfillment of natural food norms. By the 15th day, a nutritionist or a person responsible for organizing therapeutic nutrition is obliged to inform the chief physician about the state of fulfillment of food standards and, if there are deficiencies, take measures to eliminate them.

Documentation of the second group. Documents reflecting the control over the health status of catering employees

Documents reflecting the control over the health status of catering employees belong to the second group of documents on the organization of therapeutic nutrition.

Each food service worker must have:

• "Personal medical book of a catering worker" (form No. 1-lp, order No. 330 of 08/05/2003).
• "Journal of Records of Medical Research". This journal is maintained by a dietary nurse, who is obliged to monitor the timeliness of medical research by all employees of the catering department.
• Journal "Health" (form No. 2-lp, by order No. 330 of 08/05/2003). The latter is administered daily by a dietary nurse.

Documentation of the third group. Documentation for the organization of a dietary service (production documentation)

Documentation for the organization of a dietary service (production documentation):

• Employee time sheet.
• Staff schedules for the month ahead.
• A book (or folder) of orders and orders, where instructions from higher health authorities and guidelines for the organization of clinical nutrition should be carefully stored in the appropriate order.
• Journal of safety briefing.
• Ready meals assessment journal (defective).
• Journal of rejection of products and food raw materials supplied to the catering department.
• Journal of C-vitaminization of food.
• Folder of chemical analyzes of ready meals.
• Journal of Perishable Products.
• Warehouse accounting book, form No. M-17 (Order of the Ministry of Health of the USSR No. 530 dated 05.05.1983).
• Log of administrative rounds.
• Sanitary magazine.

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

The need for GOSTs

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

Federal Law No. 184-FZ of December 27, 2002 "On Technical Regulation" the principles of standardization in the Russian Federation are defined, 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") are established. This document states that technical regulations, i.e. federal laws that establish safety requirements are mandatory for application to 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 “Products of dietary (therapeutic and preventive) nutrition. Mixes proteinaceous composite dry. General technical conditions", approved by order of the Federal Agency for Technical Regulation and Metrology No. 219-st dated September 7, 2010, defined the basic requirements for specialized products intended for dietary (therapeutic and preventive) nutrition of adults and children over three years old as a protein component for preparing ready-made meals.

Want more information on dietetics?
Subscribe to the information and practical journal "Practical Dietology"!

SanPiNs and resolutions

A number of documents that define the requirements for both premises, production processes, and food products are presented sanitary regulations and norms approved by the Chief Sanitary Doctor of the Russian Federation. Here are some of them:

• Decree of the chief state sanitary doctor RF dated 05.05.2003 No. 91 "On measures to prevent diseases caused by iron deficiency in the structure of nutrition of the population."
• Sanitary and epidemiological rules and regulations SanPiN 2.3.2.1940-05 (approved by the chief state sanitary doctor on 01/17/2005, as amended on 06/27/2008) "Organization of baby food", 2.3.2 "Food raw materials and food products".
• Sanitary and epidemiological rules and regulations SanPiN2.3.2.1324-03 "Hygienic requirements for shelf life and storage conditions of food products."
• Decree of the Chief State Sanitary Doctor of the Russian Federation dated March 5, 2004 No. 9 “On additional measures to prevent diseases caused by micronutrient deficiency”.

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

Federal Law No. 184-FZ of December 27, 2002 “On Technical Regulation” (adopted State Duma December 15, 2002, approved by the Federation Council on December 18, 2002) Ch. one " General provisions» Art. 2. "Basic concepts":

"Technical regulation - 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 a decree of the President of the Russian Federation , or a decree of the Government of the Russian Federation, or a regulatory legal act federal executive body for technical regulation, and establishes mandatory requirements for the application and implementation of requirements for objects of technical regulation (products or products and processes of design [including surveys], production, construction, installation, adjustment, operation, storage, related to product requirements, transportation, sale and disposal).

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

At the level of the subject 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 a therapeutic nutrition system in a region, health authorities may issue local acts, the main criterion for which is the possibility of expanding the regulatory documents in force in the Russian Federation.

In accordance with Art. 39 federal law RF dated November 21, 2011 No. 323-FZ “On the fundamentals of protecting the health of citizens in the Russian Federation” Decree of the Government of the Russian Federation dated October 25, 2010 No. 1873-r “On approval of the Fundamentals of the State Policy of the Russian Federation in the field of healthy nutrition of the population for the period up to 2020” it is recommended that the executive authorities of the constituent entities of the Russian Federation take into account the provisions of the Fundamentals of the State Policy of the Russian Federation in the field of healthy nutrition of the population for the period up to 2020 when forming and implementing regional programs for socio-economic development.

Decree of the President of the Russian Federation No. 598 dated May 7, 2012 “On Improving the State Policy in the Sphere 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”.

To comply with the said 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 preventive) nutrition, standardize average daily food sets and the seven-day menu in medical organizations in Moscow, the Department health care of Moscow issued Order No. 1851 dated December 23, 2011 “On improving the organization of dietary (therapeutic and preventive) nutrition”, as well as a number of methodological recommendations “Card index of dishes of dietary (therapeutic and preventive) nutrition of an optimized composition for children”, regulating the algorithm (therapeutic and preventive) 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 developments of the Federal State Budgetary Institution "Research Institute of Nutrition" of the Russian Academy of Medical Sciences, optimized average daily food sets are given. Thanks to the measures taken, the unification of requirements for the organization of dietary (therapeutic and preventive) nutrition, the standardization of average daily food sets and the seven-day menu in medical organizations in Moscow, heads of medical institutions can reasonably and efficiently spend financial resources. In addition, it became necessary to introduce non-departmental control over the expenditure of funds for medical nutrition and the quality of diet in medical institutions into the work of the Department of Health.

In some constituent entities of the Russian Federation, documents have been developed to implement the main directions of the Order of the Ministry of Health of Russia dated August 05, 2003 No. 330 “On measures to improve therapeutic nutrition in medical institutions of the Russian Federation” in accordance with the Procedure for providing medical care to the population in the profile “dietology” 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 www..

As an example of the introduction of standardization of the system of therapeutic and preventive nutrition, one can imagine information mail Ministry of Health of the Territorial Fund of Compulsory Medical Insurance of the Saratov Region 09/19/2010 No. 1103-17 / 3146, No. 4529, addressed to the heads of government bodies and healthcare institutions. The document is presented in the form of guidelines "Standards for the organization of clinical nutrition" for catering for clinical and statistical groups of diseases. The clinical and statistical groups include nosological forms grouped into a set of clinical, laboratory and instrumental diagnostic features that made it possible to identify diseases (poisoning, trauma, physiological state) belonging to a group of conditions with a common etiology and pathogenesis, clinical manifestations, common 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;
   • certain clinical situation;
   • existing complications of the disease.
2. Physical indicators of the ratio of the weight and body of the patient, 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 per os, the presence of gastrostomy, enterostomy.

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

The implementation of all stages of standardization is possible when the standards for the implementation of each specific stage of work are established. The use of standards makes it possible to guarantee patients the safety, efficiency, compatibility and consistency of their medical services. In general, standards should ensure that the medical service meets the required level of quality requirements.

In order to form uniform approaches to standardization in dietetics, it is recommended to define common objects of standardization at the level of the subject of the Federation:

catering technologies in medical institutions: types, production processes, food products used in one or another type of nutrition;

• technical support for the implementation of therapeutic diets;
• food quality;
• qualification medical personnel involved in catering;
• production, sales conditions, food quality;
• accounting and reporting documentation used in the system of dietetics;
• 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 August 5, 2003 No. 330

Regional government bodies of the Russian Federation	Document
Ministry of Health of the Orenburg Region	Decree No. 338 of December 30, 2010. Information letter No. 11-l-49/1594 dated 01.12.2008.
Ministry of Health and social development Chuvash Republic	Information letter No. 03/19-7658 dated 07/27/2012.
Ministry of Health of the Republic of Bashkortostan	Order of the Ministry of Health of the Republic of Belarus dated February 28, 2006 No. 122-D "On the organization of therapeutic nutrition in medical institutions." 2. Order of the Ministry of Health of the Republic of Belarus dated December 20, 2010 No. 2813-D “On the recommended average daily food packages per patient undergoing inpatient treatment in medical and preventive institutions of the Republic of Bashkortostan”.
Ministry of Health of the Chelyabinsk Region	Order of the Ministry of Health of the Chelyabinsk Region No. 1155 dated October 23, 2009 “On Approval of the Clinical and Organizational Guidelines for Doctors on Providing Medical Care to the Population of the Chelyabinsk Region”.

At the level of a medical institution

In medical institutions, the system of organizing medical and preventive nutrition should be based on the requirements set at the federal level and at the level of the subject of the Federation.

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

Diet meals are organized and carried out by a dietitian. The execution technology is associated with the appointment of a certain diet to the patient in accordance with the approved diet nomenclature. Organization of the work of the catering unit, the formation of nutritional 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 using food products in cooking, including dietary products, specialized (mixtures of protein composite dry) and baby food, is the basis for the formation of a system of therapeutic nutrition 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 the nutritional support team. In its absence, this task falls on physicians, usually resuscitators, who specialize in nutritional support, and on departmental nurses 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 conducting 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 August 5, 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 meet the energy and plastic needs of the body in a natural way in a number of diseases. The extract 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 Card of observation of the patient receiving enteral nutrition (insert in the medical record of the inpatient, registration form No. 003/U).

The purchase of enteral mixtures is carried out according to 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 complete enteral nutrition, the patient should be removed from the diet; when conducting partial enteral nutrition, the patient should be removed from those meals that are replaced by enteral mixtures. Information about this should be recorded in the patient's medical history and transferred to the catering department.

Parenteral nutrition is organized and carried out by a nutritional support team, resuscitators, as a rule, in intensive care units (wards) and intensive care units. Mixtures for parenteral nutrition are medicines and related to drug therapy. When carrying out total parenteral nutrition, the patient should be taken off the diet. Information about this should be recorded in the patient's medical history.

Enteral and parenteral nutrition are artificial types of nutrition that are used only for medical reasons when it is impossible to adequately meet the energy and plastic needs of the body naturally in a number of diseases and are presented in a number of reference manuals and recommendations for nutritional support in intensive care and resuscitation. These sections are not within the competence of a dietitian, 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 entry of which into the human body is possible without the phase of gastric digestion.

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

• standard for regulatory support for the implementation of federal legislation in the organization of medical nutrition in medical institutions;
• standard for the range of services and works in the organization of catering in medical institutions;
• quality standard for clinical nutrition;
• standard for prescribing therapeutic diets;
• standard of requirements for the organization of clinical nutrition in stationary medical institutions;
• standards for the organization of clinical nutrition for various clinical and statistical groups of patients;
• standard peer review catering in medical institutions.

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

In order to organize effective and high-quality therapeutic nutrition, which is part of the complex therapy of the patient, it is necessary to organize a Council for therapeutic nutrition in the institution. Despite the fact that it is an advisory body, its main tasks are to control the quality of therapeutic nutrition and the introduction of new therapeutic nutrition technologies. The Therapeutic Nutrition Council not only approves the nomenclature of diets, specialized dietary products (composite protein mixtures), mixtures for enteral nutrition, dietary supplements to be introduced in this institution, but also conducts an internal examination of the usefulness and effectiveness of therapeutic 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 should be approved by the Medical Nutrition Council, since the most important role in the effectiveness and quality of therapeutic nutrition is played by the continuity between the catering unit and departments, the dietitian, attending physicians and specialists involved in the treatment of patients. The practical implementation of unified regulatory requirements for the organization of clinical nutrition will ensure planning and formation of financing from the standpoint of rational use financial resources.

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

List of works	Measures for the implementation of works
Preparation of regulatory documents for catering	Preparation of an order for the organization of dietary nutrition. Organization of the work of the Council for Clinical Nutrition.
Carrying out work on the purchase of food	Carrying out work on the purchase of natural food products. Carrying out works on the purchase of specialized food products (mixtures of protein composite dry).
Carrying out work to provide and update the catering unit and pantry equipment	Carrying out work to provide equipment: technological mechanical; technological thermal; non-mechanized; technological refrigeration; for catering.

Application of specialized products

Nutrition of the patient is the basis for restoring protein losses that occur during illness, adaptation 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 methodological recommendations for the organization of therapeutic nutrition in medical institutions. Currently, the composition of dietary products includes the so-called specialized foods. Mixtures containing the main macro- and micronutrients in optimal ratios or in the amount necessary to correct the main components of food can be used as specialized medical nutrition products in medical institutions.

Specialized therapeutic foods are specially designed foods for the nutrition of sick people in order to enrich diets or replace conventional foods that are restricted or prohibited for medical reasons.

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. Dietitians quite 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 to include in dietary meals during protein correction? The answer to this question is quite simple: the selected product must comply with the requirements of GOST R 53861-2010, and it must have the appropriate certification and quality documents.

A separate issue in the organization of therapeutic nutrition is the availability in the hospital of specialized therapeutic nutrition 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 to the body is limited, or they are not there at all. So, with phenylketonuria, the amino acid phenylalanine, which is perceived by the body as a poison due to a defect in the enzyme system, is completely excluded from the diet. That is why for children suffering from phenylketonuria, galactosemia, celiac disease, there are specialized health food products.

Order of the Ministry of Health and Social Development of Russia dated January 9, 2007 No. 1 “On approval of the list of medical devices and specialized health food products ...” approved the List of specialized therapeutic food products for children with disabilities. This list includes specialized medical nutrition products:

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

Currently, within the framework of the Unified Sanitary Rules of the EurAsEC Customs Union, they are defined as subject to mandatory state registration specialized food products, including baby food products, products for pregnant and lactating women, dietary (therapeutic and preventive) food products, food products for athletes. Among the documents of the Customs Union regulating the issues of specialized nutrition, it is necessary to highlight the Decision of the Commission of the Customs Union dated May 28, 2010 No. 299 “On the application of sanitary measures in customs union”, which defines a list of specialized products for therapeutic nutrition of children.

The use of specialized food products opens up great opportunities for organizing therapeutic and preventive nutrition. With the help of rationally constructed diets, an increase in the overall stability of the body, the use of the properties of food components, their protective effect on the structure and function of the most affected organs, and compensation for excessive consumption of food and biologically active substances due to diseases are ensured.

Federal Law of November 21, 2011 No. 323-FZ “On the Fundamentals of Protecting the Health of Citizens in the Russian Federation”, Ch. 5 "Organization of health care" Art. 39 "Healing nutrition":

“3. Specialized medical food products 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 impaired or lost body functions as a result of the disease, the prevention of these disorders, as well as on increasing the adaptive capabilities of the body.

Order of the Ministry of Health of the Russian Federation of August 5, 2003 N 330
"On measures to improve clinical nutrition in medical institutions of the Russian Federation"

With changes and additions from:

For the application of this order, see the letter of the Ministry of Health of the Russian Federation of April 7, 2004 N 2510 / 2877-04-32 and the letter of the Ministry of Health and Social Development of the Russian Federation of July 11, 2005 N 3237-BC

In order to implement the Concept of the 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 *, improve the organization of clinical nutrition and increase the effectiveness of its use in the complex treatment of patients, I order:

1.1. Regulations on the organization of the activities of a dietitian (Appendix N 1);

1.2. Regulations on the organization of the activities of a dietary nurse (Appendix N 2);

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

1.4. Instructions for the organization of therapeutic nutrition in medical institutions (Appendix N 4);

1.5. Instructions for the organization of enteral nutrition in medical institutions (Appendix N 5);

2. To impose control over the implementation of this order on the Deputy Minister R.A. Khalfin.

Order 330 on Clinical Nutrition

MINISTRY OF HEALTH OF THE RUSSIAN FEDERATION

ABOUT IMPROVEMENT MEASURES
THERAPEUTIC NUTRITION IN THERAPEUTIC AND PREVENTIVE
INSTITUTIONS OF THE RUSSIAN FEDERATION

(as amended by the Orders of the Ministry of Health and Social Development of the Russian Federation
dated 07.10.2005 No. 624, dated 10.01.2006 No. 2, dated 26.04.2006 No. 316)

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 dated 10.08.1998 No. 917 *, improve the organization of clinical nutrition and increase the effectiveness of its use in the complex treatment of patients, I order:

———————————
* Collection of legislation of the Russian Federation, 08/24/1998, No. 8, art. 4083.

a. Regulations on the organization of the activities of a dietitian (Appendix No. 1);
b. Regulations on the organization of the activities of a dietary nurse (Appendix No. 2);
c. Regulations on the Council for Clinical Nutrition in Medical Institutions (Appendix No. 3);
d. Instructions for organizing therapeutic nutrition in medical institutions (Appendix No. 4);
e. Instructions for the organization of enteral nutrition in medical institutions (Appendix No. 5).

2. To impose control over the implementation of this Order on the Deputy Minister R.A. Khalfin.

Minister
Yu.L. Shevchenko

Application No. 1
Approved
Order of the Ministry
health care
Russian Federation
dated 05.08.2003 No. 330

POSITION
ABOUT THE ORGANIZATION OF THE ACTIVITIES OF A NUTRITIONAL DOCTOR

The position of a dietitian is appointed by a specialist doctor who has training in clinical nutrition and a certificate in the specialty "dietology".

A dietitian is responsible for organizing therapeutic nutrition and its adequate application in all departments of health care institutions.

A dietitian supervises dietary nurses, oversees the work of the catering unit.

The dietitian must:

advise doctors of departments on the organization of medical nutrition;

advise patients on therapeutic and rational nutrition;

conduct a random check of case histories according to the prescribed diets and the stages of diet therapy;

analyze the effectiveness of therapeutic nutrition;

to control the correctness of the laying of products during the preparation of dishes;

prepare documentation for the organization of medical nutrition:
- layout cards;
— seven-day menu;
- a seven-day summary menu - summer and winter version;

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

to control the quality of prepared food before issuing it to the departments by taking a sample at each meal;

together with the heads of departments, determine the list and number of grocery home transfers for a patient who is being treated in a medical institution;

control the timeliness of preventive medical examinations of catering and pantry workers and prevent persons who have not undergone preventive medical examinations and patients with pustular, intestinal diseases, tonsillitis from work;

systematically organize an increase in the level of qualification of workers in the catering department on issues of clinical nutrition;

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

to improve the level of professional qualifications on improvement cycles in nutrition at least 1 time in 5 years.

Application No. 2
Approved
Order of the Ministry
health care
Russian Federation
dated 05.08.2003 No. 330

POSITION
ON ORGANIZATION OF MEDICAL ACTIVITIES
SISTERS DIETARY

A specialist with a secondary medical education is appointed to the position of a dietary nurse, having special training in clinical nutrition and a certificate in the specialty "Dietetics".

A dietary nurse works under the guidance of a dietitian.

The dietary nurse monitors the work of the catering unit and the observance of sanitary and hygienic rules by catering workers.

The dietary nurse is required to:

check the quality of products when they arrive at the warehouse and catering department; control the correct storage of food stock;

cook daily under the supervision of a dietitian and with the participation of the production manager the menu layout (or menu-requirement) in accordance with the card index of dishes and the summary menu approved by the Council for Therapeutic Nutrition;

to control the correctness of the laying of products during cooking and grading finished products, carry out sampling of prepared food;

control the correctness of the distribution of dishes from the catering unit to the departments in accordance with the "distribution sheet";

to exercise control over: the sanitary condition of the premises of the catering department, distributing, pantry, inventory, utensils, as well as the implementation of the rules of personal hygiene by the employees of the catering department;

organize and personally participate in conducting classes with paramedical personnel and catering workers on therapeutic nutrition;

maintain medical records;

to carry out timely preventive medical examinations of catering, dispensing and buffet workers and not allow people who have not undergone a preventive medical examination, and patients with pustular, intestinal diseases, tonsillitis, to work;

level up vocational training at least once every 5 years.

Application No. 3
Approved
Order of the Ministry
health care
Russian Federation
dated 05.08.2003 No. 330

POSITION
ABOUT THE THERAPEUTIC NUTRITION COUNCIL
TREATMENT AND PREVENTIVE INSTITUTIONS

(As amended by the Order of the Ministry of Health and Social Development of the Russian Federation dated April 26, 2006 No. 316)

The Medical Nutrition Council is an advisory body and is created in a medical institution with a number of beds of 100 or more.

The number of members of the Medical Nutrition Council and its personal composition is approved by the Order of the head physician of the institution.

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

Tasks of the Council for Therapeutic Nutrition:

1. improvement of the organization of medical nutrition in a medical institution;
2. introduction of new technologies for preventive, dietary and enteral nutrition;
3. approval of the nomenclature of diets, mixtures for enteral nutrition, dry protein composite mixtures for therapeutic nutrition, biologically active additives to be introduced in this healthcare institution; (As amended by the Order of the Ministry of Health and Social Development of the Russian Federation dated April 26, 2006 No. 316)
4. approval of seven-day menus, a card file of dishes and a set of mixtures for enteral nutrition;
5. improvement of the ordering system for dietary kits and mixtures for enteral nutrition;
6. development of forms and plans for advanced training of employees in clinical nutrition;
7. control over the organization of therapeutic nutrition and analysis of the effectiveness of diet therapy for various diseases.
8. The Therapeutic Nutrition Council meets as needed, but at least once every three months.

Application No. 4
Approved
Order of the Ministry
health care
Russian Federation
dated 05.08.2003 N 330

INSTRUCTIONS
ON THE ORGANIZATION OF THERAPEUTIC FOOD
IN MEDICAL AND PREVENTIVE INSTITUTIONS

in red. Orders of the Ministry of Health and Social Development of the Russian Federation
No. 624 of 07.10.2005, No. 2 of 10.01.2006, No. 316 of 26.04.2006)

The organization of therapeutic nutrition in a medical 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, food preparation technology and the average daily set of products.

The previously used diets of the number system (diets No. 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 main standard diet and its variants in a medical institution, in accordance with their profile, they use:

• surgical diets (0-I; 0-II; 0-III; 0-IV; diet for ulcer bleeding, diet for gastric stenosis), etc.;
• specialized diets: high-protein diet for active tuberculosis (hereinafter - high-protein diet (m));
  (the paragraph was introduced by the Order of the Ministry of Health and Social Development of the Russian Federation dated April 26, 2006 No. 316)
• unloading diets (tea, sugar, apple, rice-compote, potato, cottage cheese, juice, meat, etc.);
• special diets (potassium, magnesium, probe diet, diets for myocardial infarction, diets for unloading dietary therapy, vegetarian diet, etc.).

Individualization of the chemical composition and caloric content of standard diets is carried out by selecting the medical nutrition dishes available in the card file, increasing or decreasing the number of buffet products (bread, sugar, butter), controlling home delivery of food for patients undergoing treatment in a medical institution, and also by use in therapeutic and enteral nutrition of biologically active food supplements and ready-made specialized mixtures. To correct the diet, 20-50% of the protein of ready-made specialized mixtures can be included (table 1a).
(as amended by the Order of the Ministry of Health and Social Development of the Russian Federation dated 10.01.2006 No. 2)

Note:
Order of the Ministry of Finance of the Russian Federation dated December 21, 2005 No. 152n became invalid from January 1, 2007 in connection with the publication of the Order of the Ministry of Finance of the Russian Federation dated December 8, 2006 No. 168n. Applicable Application Guidelines budget classification Russian Federation approved by the Order of the Ministry of Finance of the Russian Federation dated December 25, 2008 No. 145n.

Acquisition of dry composite protein mixtures for clinical 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 No. 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) under article 340 of the economic classification of expenditures of the budgets of the Russian Federation "Increase in the cost of inventories" with the assignment of ready-made specialized mixtures for medical nutrition to the section "food (payment for food), including food rations to servicemen and persons equated to them.
(the paragraph was introduced by the Order of the Ministry of Health and Social Development of the Russian Federation dated April 26, 2006 No. 316)

The nomenclature of permanent diets in each medical institution is established in accordance with its profile and approved by the Council for Clinical Nutrition. In all medical institutions, at least four meals a day are established, according to indications in separate departments or for certain categories patients (peptic ulcer of the 12 duodenal ulcer, disease of the operated stomach, diabetes mellitus, etc.) use more frequent meals. The diet is approved by the Therapeutic Nutrition Council.

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

Control of the correctness of the diet therapy carried out should be carried out by checking the compliance of the diets received by patients (in terms of a set 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 institution is carried out by the chief physician, and in his absence, the deputy for the medical unit.

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

The nutritionist is subordinated to dietary nurses and all catering workers who provide therapeutic nutrition in a medical institution in accordance with this Order.

At the catering department of a medical institution, the head of production (chef, senior cook) controls the compliance with the cooking technology and the output of ready-made dietary dishes; food to departments.

All issues related to the organization of clinical nutrition in a medical institution are systematically (at least once a quarter) heard and resolved at meetings of the Medical Nutrition Council.

Table 1
to the Instructions for Organizing
preventive institutions

Characteristics, chemical composition and energy value of standard diets,
used in healthcare facilities (hospitals, etc.)

www.santegra.spb.ru

The order of the Ministry of Health of Russia approved the norms of clinical nutrition

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

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

The composition of the components for the preparation of diet food also includes protein composite dry mixes.

Approaches to the creation of dry composite protein mixtures and their recipes were developed back in the 70s of the last century by Academician A.A. Pokrovsky. These products are made on the basis of whey milk proteins with the inclusion of lecithin, polyunsaturated fatty acids, dietary fiber, vitamins and minerals, maltodextrin (source of carbohydrates).
Dry composite protein mixes 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 excess 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 that were carried out for two years at the Federal State Budgetary Institution "Research Institute of Nutrition" of the Russian Academy of Medical Sciences, the Federal State Budgetary Institution "Central Research Institute of Tuberculosis" RAMS and others.
Dry composite protein mixes are produced in accordance with GOST R 53861-2010 “Products of dietary (therapeutic and preventive) nutrition. Mixes proteinaceous composite dry. General technical conditions".
The mixtures are included in State Register and are used as a component for the preparation of dishes for therapeutic and preventive nutrition of children from 3 years of age and adults, and workers employed in work with harmful and especially harmful conditions labor.
Composite protein powder 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 clinical nutrition in treatment and prophylactic institutions of the Russian Federation") with changes as of April 26, 2006, introduced by orders of the Ministry of Health and Social Development of Russia No. 2 dated 10.01.2006. and No. 316 dated April 26, 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 clinical nutrition.

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

The draft order was publicly discussed at single portal disclosure of information on the preparation by federal executive bodies of draft regulatory legal acts and the results of their public discussion. There were no comments or suggestions for the draft order.

www.rosminzdrav.ru

Organization of medical nutrition



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 November 21, 2011 No. 323-FZ “On the Fundamentals of Protecting the Health of Citizens in the Russian Federation” defines the rules governing the basics of the organization of clinical nutrition.

Organization of medical nutrition at the federal level

The organization of medical nutrition at the federal level takes place in accordance with the requirements of the following regulations:

Federal Law No. 323-FZ dated November 21, 2011 “On the Fundamentals of Protecting the Health 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, guidelines and information letters (see the text of the document on the website www.praktik-dietolog.ru in the section " The legislative framework»).

Order of the Ministry of Health and Social Development of Russia dated June 24, 2010 No. 474n “On Approval of the Procedure for Providing Medical Assistance to the Population in the Dietetics Profile”. The order is a regulatory document that defines the principles, procedure and system for organizing medical nutrition in the Russian Federation.

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

Regulatory documents, the names of which are presented in Table. 1, are currently valid throughout our country and are mandatory for medical organizations when organizing medical nutrition.

The organization of therapeutic and preventive nutrition of patients undergoing inpatient treatment must be carried out in all medical organizations that have round-the-clock beds and day-care beds with food, sanatoriums in accordance with Order of the Ministry of Health of Russia dated August 5, 2003 No. 330 “On measures to improve clinical nutrition in medical institutions of the Russian Federation”.

The documents approved by this order are mandatory for use in organizing the nutrition system, document flow, accounting for food consumption, prescribing therapeutic 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 therapeutic nutrition in medical institutions. It defines the following standards for the organization of therapeutic nutrition:

• Characteristics, chemical composition and energy value of standard diets used in healthcare facilities (hospitals, etc.).
• The ratio of natural food products and specialized food products in the patient's daily diet.
• Interchangeability of products in the preparation of dietary dishes.
• Replacement of products for proteins and carbohydrates.
• The procedure for extracting food for patients in medical institutions.
• The procedure for monitoring the quality of prepared food in a medical institution.
• Recommendations for the equipment of the catering unit and pantry.
• Transportation of prepared food.
• Sanitary and hygienic regime of the catering unit and pantry.
• The list of documentation of the catering department for the discharge of foodresearch and control over the quality of prepared food in medical institutions.

In connection with the issuance of Order No. 330, the previously used standards according to the ratio of the chemical composition of diets, the interchangeability of food products and the replacement of products not to be used in medical facilities. For the first time, a federal departmental order introduced a single nomenclature of standard diets for all medical institutions.

Instructions for the organization of enteral nutrition in medical institutions are also mandatory. In order to standardize the delivery 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 malnutrition;
• observation card of a patient receiving enteral nutrition (insert in the medical record of an inpatient, registration form 003/U);
• methodology for determining the energy needs of the body;
• the choice 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 certain diseases;
• ways of introducing enteral nutritional mixtures.

Federal Departmental Order of the Ministry of Health of the USSR dated May 5, 1983 No. 530 “On approval of instructions for accounting for food products in medical and preventive and other health care institutions that are on the state budget of the USSR”(as amended on 05/17/1984, 12/30/1987) and Order of the Ministry of Health of Russia dated 08/05/2003 No. 330 "On measures to improve therapeutic nutrition in medical institutions of the Russian Federation" approved the accounting and document management system. It is necessary to maintain documentation in accordance with the requirements of these orders, since it is not only a system for recording patients put on food, but also a system for spending food, controlling the spending of financial resources.

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

• Documentation intended for the issuance of food products and accounting, appropriations issued for them.
• Documents reflecting the control over the health status of catering employees.
• Documentation on the organization of a dietary service (production documentation).

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

"On the basics of protecting the health of citizens in the Russian Federation", Ch. 5 "Organization of health care" Art. 39 "Healing nutrition":

"one. Therapeutic nutrition is nutrition that ensures 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 underlying and concomitant diseases, and performing preventive and therapeutic tasks.

Federal Law of November 21, 2011 No. 323-FZ “On the Fundamentals of Protecting the Health of Citizens in the Russian Federation”, Ch. 5 "Organization of health care" Art. 39 "Healthy nutrition": "Norms of medical nutrition are approved by the authorized federal executive body."

Table 1. Regulatory documents that are mandatory for implementation by medical organizations in the organization of medical nutrition

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

The main reporting forms, which are compiled to provide food for patients admitted to the hospital, belong to the documents of the first group.

The main document in this group is a card file of dietary dishes (see details about this document in the article "Specialized card file of dietary dishes", PD No. 1, or on the website www.praktik-dietolog.ru in the section "To the taste of the patient"). Without a card file, it is impossible to correctly compose a seven-day menu, a menu layout, i.e. documents that provide information about meeting 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 underlying and concomitant diseases. The card file is of particular importance in the proper organization of clinical nutrition. If it is available, it is possible to calculate what the patient actually receives during the day, plan the work of the catering department, facilitate organizational measures, calculate the consumption of products and the allocations allocated for them.

Seven Day Consolidated Menu

Based on the card index, a seven-day summary menu is compiled. Using the seven-day menu in the work, it is possible to plan the volume of food purchases, organize the work of the catering staff, and develop standards in the preparation of various dishes.

It is recommended to have two menus - autumn-summer and winter-spring, as the assortment of products changes depending on the time of year, in addition, some products have a 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 for Clinical Nutrition.

The number of diets and their set should be individual for each institution and adapted to its profile. When compiling the menu, it is very important to take into account the qualitative variety of dishes during the day and the 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 diets, their energy value, the correct use of natural food norms, the consumption of appropriations allocated 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 relevant 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 stored in the accounting department, and the second - with the dietary nurse.

Each layout card contains data: the name of the dish, a list of diets for which this dish is recommended to be used; a list of products needed to prepare 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 the heat treatment of the finished dish; its estimated cost; cooking technology.

Diet nomenclature

Standard diets- these 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 products used as the main therapeutic diets, as well as 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 foods 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 foods from the diet. If he has a decrease in body mass index below the standard values, 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 mandatory manner in a medical institution refer to accounting and reporting documents. In medical institutions, in order to optimize work, automated document management systems are being introduced that ensure the implementation of evidence-based principles of nutrition.

Information about the presence of patients who are on meals, are submitted in the form of form No. 22 in accordance with order No. 330 of 05.08.2003. This form is the basis for planning and distributing patients according to diets and meals.

The main legal document, on the basis of which food products are issued from the warehouse to the catering unit for cooking and appropriations for food are spent, 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 officer, who calculates the total number of all products needed to prepare all the dishes for their release from the warehouse.

Requirement for the issuance of products(form No. 45-M3, order No. 330 dated 05.08.2003). This document is made in two copies. One copy remains after the issuance 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 daily supply pantry. The production manager (chef) bears full financial responsibility for them. The next day, he distributes food to the chefs 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.

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

If the number of patients changes compared to the menu layout data (or menu requirements) by more than three people, the dietary nurse prepares "Information on the movement of patients". In accordance with this document, it draws up 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 compared to the previous day, then the products not used for cooking are returned to the warehouse in the same form with the indication “Return” (except for the products already put into the boiler when preparing breakfast).

Form No. 23-MZ "Distribution list for vacation to food ration departments"(meal: breakfast, lunch, dinner, etc.). This document serves as the basis for issuing ready-made meals to hospital departments.

The menu is recommended to be posted at the entrance to the dining room so that patients can familiarize themselves with it. Responsible for the organization of clinical 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 for the past month. The accountant must prepare it by the 10th day of the next month and submit it to a dietitian or a person responsible for organizing clinical nutrition for analysis of the fulfillment of natural food norms. By the 15th day, a nutritionist or a person responsible for organizing therapeutic nutrition is obliged to inform the chief physician about the state of fulfillment of food standards and, if there are deficiencies, take measures to eliminate them.

Documentation of the second group. Documents reflecting the control over the health status of catering employees

Documents reflecting the control over the health status of catering employees belong to the second group of documents on the organization of therapeutic nutrition.

Each food service worker must have:

• "Personal medical book of a catering worker" (form No. 1-lp, order No. 330 of 08/05/2003).
• "Journal of Records of Medical Research". This journal is maintained by a dietary nurse, who is obliged to monitor the timeliness of medical research by all employees of the catering department.
• Journal "Health" (form No. 2-lp, by order No. 330 of 08/05/2003). The latter is administered daily by a dietary nurse.

Documentation of the third group. Documentation for the organization of a dietary service (production documentation)

Documentation for the organization of a dietary service (production documentation):

• Employee time sheet.
• Staff schedules for the month ahead.
• A book (or folder) of orders and orders, where instructions from higher health authorities and guidelines for the organization of clinical nutrition should be carefully stored in the appropriate order.
• Journal of safety briefing.
• Ready meals assessment journal (defective).
• Journal of rejection of products and food raw materials supplied to the catering department.
• Journal of C-vitaminization of food.
• Folder of chemical analyzes of ready meals.
• Journal of Perishable Products.
• Warehouse accounting book, form No. M-17 (Order of the Ministry of Health of the USSR No. 530 dated 05.05.1983).
• Log of administrative rounds.
• Sanitary magazine.

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

The need for GOSTs

At the federal level, a number of legal documents have been introduced to ensure the quality of food products and the safety of their use in public catering, including medical and preventive, in medical institutions (see Table 2).

Federal Law No. 184-FZ of December 27, 2002 "On Technical Regulation" the principles of standardization in the Russian Federation are defined, 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") are established. This document states that technical regulations, i.e. federal laws that establish safety requirements, are mandatory for application to 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 “Products of dietary (therapeutic and preventive) nutrition. Mixes proteinaceous composite dry. General technical conditions", approved by order of the Federal Agency for Technical Regulation and Metrology No. 219-st dated September 7, 2010, defined the basic requirements for specialized products intended for dietary (therapeutic and preventive) nutrition of adults and children over three years old as a protein component for preparing ready-made meals.

Want more information on dietetics?
Subscribe to the information and practical journal "Practical Dietology"!

SanPiNs and resolutions

A number of documents that define the requirements for both premises, production processes, and food products are represented by sanitary rules and regulations approved by the Chief Sanitary Doctor of the Russian Federation. Here are some of them:

• Decree of the Chief State Sanitary Doctor of the Russian Federation dated May 5, 2003 No. 91 "On measures to prevent diseases caused by iron deficiency in the diet of the population."
• Sanitary and epidemiological rules and regulations SanPiN 2.3.2.1940-05 (approved by the chief state sanitary doctor on 01/17/2005, as amended on 06/27/2008) "Organization of baby food", 2.3.2 "Food raw materials and food products".
• Sanitary and epidemiological rules and regulations SanPiN2.3.2.1324-03 "Hygienic requirements for shelf life and storage conditions of food products."
• Decree of the Chief State Sanitary Doctor of the Russian Federation dated March 5, 2004 No. 9 “On additional measures to prevent diseases caused by micronutrient deficiency”.

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

Federal Law No. 184-FZ of December 27, 2002 “On Technical Regulation” (adopted by the State Duma on December 15, 2002, approved by the Federation Council on December 18, 2002), Ch. 1 "General provisions" art. 2. "Basic concepts":

"Technical regulation - 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 a decree of the President of the Russian Federation , or a decree of the Government of the Russian Federation, or a regulatory legal act of the federal executive body for technical regulation, and establishes mandatory requirements for the application and execution of requirements for objects of technical regulation (products or products and design processes related to product requirements [including surveys], production , construction, installation, adjustment, operation, storage, transportation, sale and disposal)”.

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

At the level of the subject 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 a therapeutic nutrition system in a region, health authorities may issue local acts, the main criterion for which is the possibility of expanding the regulatory documents in force in 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 Protecting the Health of Citizens in the Russian Federation” Order of the Government of the Russian Federation of October 25, 2010 No. 1873-r “On Approval of the Fundamentals of the State Policy of the Russian Federation in the field of healthy nutrition of the population for the period up to 2020 G." it is recommended that the executive authorities of the constituent entities of the Russian Federation take into account the provisions of the Fundamentals of the State Policy of the Russian Federation in the field of healthy nutrition of the population for the period up to 2020 when forming and implementing regional programs for socio-economic development.

Decree of the President of the Russian Federation No. 598 dated May 7, 2012 “On Improving the State Policy in the Sphere 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”.

To comply with the said 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 preventive) nutrition, standardize average daily food sets and the seven-day menu in medical organizations in Moscow, the Department health care of Moscow issued Order No. 1851 dated December 23, 2011 “On improving the organization of dietary (therapeutic and preventive) nutrition”, as well as a number of methodological recommendations “Card index of dishes of dietary (therapeutic and preventive) nutrition of an optimized composition for children”, regulating the algorithm (therapeutic and preventive) 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 developments of the Federal State Budgetary Institution "Research Institute of Nutrition" of the Russian Academy of Medical Sciences, optimized average daily food sets are given. Thanks to the measures taken, the unification of requirements for the organization of dietary (therapeutic and preventive) nutrition, the standardization of average daily food sets and the seven-day menu in medical organizations in Moscow, heads of medical institutions can reasonably and efficiently spend financial resources. In addition, it became necessary to introduce non-departmental control over the expenditure of funds for medical nutrition and the quality of diet in medical institutions into the work of the Department of Health.

In some constituent entities of the Russian Federation, documents have been developed to implement the main directions of the Order of the Ministry of Health of Russia dated August 05, 2003 No. 330 “On measures to improve therapeutic nutrition in medical institutions of the Russian Federation” in accordance with the Procedure for providing medical care to the population in the profile “dietology” 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 site www. praktik-dietolog.ru in the "Legislative framework" section.

As an example of the introduction of standardization of the therapeutic and preventive nutrition system, we can present the information letter of the Ministry of Health of the Territorial Fund of Compulsory Medical Insurance of the Saratov Region dated 19.09.2010 No. 1103-17 / 3146, No. 4529, addressed to the heads of government bodies and healthcare institutions. The document is presented in the form of guidelines "Standards for the organization of clinical nutrition" for catering for clinical and statistical groups of diseases. Clinical-statistical groups include nosological forms grouped into a set of clinical, laboratory and instrumental diagnostic signs, which made it possible to identify diseases (poisoning, trauma, physiological state) belonging to a group of conditions with a common etiology and pathogenesis, clinical manifestations, general approaches to treatment and corrections (see the text of the document on the website www.praktik-dietolog.ru in the "Legislative Framework" section). 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;
   • certain clinical situation;
   • existing complications of the disease.
2. Physical indicators of the ratio of the weight and body of the patient, the severity of protein-energy deficiency:
   • the degree of violation of the nutritional status;
   • body mass index.
   • 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 per os, the presence of gastrostomy, enterostomy.

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

     The implementation of all stages of standardization is possible when the standards for the implementation of each specific stage of work are established. The use of standards makes it possible to guarantee patients the safety, efficiency, compatibility and consistency of their medical services. In general, standards should ensure that the medical service meets the required level of quality requirements.

     In order to form uniform approaches to standardization in dietetics, it is recommended to define common objects of standardization at the level of the subject of the Federation:

     catering technologies in medical institutions: types, production processes, food products used in one or another type of nutrition;

   • technical support for the implementation of therapeutic diets;
   • food quality;
   • qualification of medical personnel involved in catering;
   • production, sales conditions, food quality;
   • accounting and reporting documentation used in the system of dietetics;
   • 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 August 5, 2003 No. 330

   At the level of a medical institution

   In medical institutions, the system of organizing medical and preventive nutrition should be based on the requirements set at the federal level and at the level of the subject of the Federation.

   At the same time, when organizing therapeutic nutrition directly in a medical institution, various types of therapeutic nutrition (dietary, enteral and parenteral) are used, 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 carried out by a dietitian. The execution technology is associated with the appointment of a certain diet to the patient in accordance with the approved diet nomenclature. Organization of the work of the catering unit, the formation of nutritional 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 using food products in cooking, including dietary products, specialized (mixtures of protein composite dry) and baby food, is the basis for the formation of a system of therapeutic nutrition 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 the nutritional support team. In its absence, this task falls on physicians, usually resuscitators, who specialize in nutritional support, and on departmental nurses 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 conducting 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 August 5, 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 meet the energy and plastic needs of the body in a natural way in a number of diseases. The extract 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 Card of observation of the patient receiving enteral nutrition (insert in the medical record of the inpatient, registration form No. 003/U).

   The purchase of enteral mixtures is carried out according to 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 complete enteral nutrition, the patient should be removed from the diet; when conducting partial enteral nutrition, the patient should be removed from those meals that are replaced by enteral mixtures. Information about this should be recorded in the patient's medical history and transferred to the catering department.

   Parenteral nutrition is organized and carried out by a nutritional support team, resuscitators, as a rule, in intensive care units (wards) and intensive care units. Mixtures for parenteral nutrition are drugs and belong to drug therapy. When carrying out total parenteral nutrition, the patient should be taken off the diet. Information about this should be recorded in the patient's medical history.

   Enteral and parenteral nutrition are artificial types of nutrition that are used only for medical reasons when it is impossible to adequately meet the energy and plastic needs of the body naturally in a number of diseases and are presented in a number of reference manuals and recommendations for nutritional support in intensive care and resuscitation. These sections are not within the competence of a dietitian, 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 entry of which into the human body is possible without the phase of gastric digestion.

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

   • standard for regulatory support for the implementation of federal legislation in the organization of medical nutrition in medical institutions;
   • standard for the range of services and works in the organization of catering in medical institutions;
   • quality standard for clinical nutrition;
   • standard for prescribing therapeutic diets;
   • standard of requirements for the organization of clinical nutrition in stationary medical institutions;
   • standards for the organization of clinical nutrition for various clinical and statistical groups of patients;
   • standard for expert evaluation of catering in medical institutions.

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

   In order to organize effective and high-quality therapeutic nutrition, which is part of the complex therapy of the patient, it is necessary to organize a Council for therapeutic nutrition in the institution. Despite the fact that it is an advisory body, its main tasks are to control the quality of therapeutic nutrition and the introduction of new therapeutic nutrition technologies. The Therapeutic Nutrition Council not only approves the nomenclature of diets, specialized dietary products (composite protein mixtures), mixtures for enteral nutrition, dietary supplements to be introduced in this institution, but also conducts an internal examination of the usefulness and effectiveness of therapeutic 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 should be approved by the Medical Nutrition Council, since the most important role in the effectiveness and quality of therapeutic nutrition is played by the continuity between the catering unit and departments, the dietitian, attending physicians and specialists involved in the treatment of patients. The practical implementation of unified regulatory requirements for the organization of clinical nutrition will ensure the planning and formation of financing from the standpoint of the rational use of financial resources.

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

   MINISTRY OF HEALTH
   Khabarovsk Territory

   
   In order to implement the Concept of the state policy in the field of healthy nutrition of the population of the Khabarovsk Territory, improve the organization of clinical nutrition in the medical and preventive institutions of the region
   
   I declare:
   
   1. .
   
   I order:
   
   1. Heads of health authorities municipalities, medical and preventive institutions of the region:
   1.1. Accept for execution 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 and preventive institutions.
   1.2. Arrange for medical workers subordinate institutions a seminar on the study of the above-mentioned Order before 10.06.2004.
   1.3. Ensure the introduction of a new range of diets, use in therapeutic 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) reduction or increase in buffet products, biologically active food supplements (including soy products) , bread made from sprouted grains or with lamidan) and ready-made specialized mixtures.
   1.4. staff vacant positions nutritionists.
   1.5. To amend the existing Regulations on the Council for Clinical Nutrition, on the organization of the activities of a dietitian, a nurse in a dietary medical and preventive 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 Health Professionals of the Ministry of Health of the Khabarovsk Territory for doctors and paramedical workers, to ensure that they are sent to specialized courses in the system of postgraduate education.
   2. First Deputy Minister of Health of the Khabarovsk Territory Tropnikova V.M. to provide for in the programs of postgraduate training of medical workers the issues of organizing therapeutic nutrition in medical institutions.
   3. To take into account the Order of the Ministry of Health of the Russian Federation of February 12, 2004 N 95 "On the cancellation of the order of April 23, 1985 N 540 and of June 14, 1989 N 369".
   4. Information on the execution of this order must be submitted by 01.10.2004.
   5. To impose control over the execution of this order on the Deputy Minister of Health of the Khabarovsk Territory A.Ya. Derkach.