Procedures for Keeping Medical Documents

[20 September 2011]

Issued pursuant to
Section 59 of the Medical Treatment Law

I. General Provisions

1. This Regulation prescribes the procedures for keeping medical documents in medical treatment institutions (hereinafter - the document keeping procedures).

[20 September 2011]

2. The document keeping procedures shall be binding on all medical treatment institutions of the Republic of Latvia.

3. The document keeping procedures shall be a part of the mandatory requirements defined for a medical treatment institution.

[13 October 2009]

4. The implementation of this Regulation shall be controlled by the Health Inspectorate.

[15 April 2008]

II. Entries in Medical and Register Documentation

5. Medical documents regarding receipt of a primary health care, secondary health care and emergency medical assistance (hereinafter - the medical entries) shall form a unified information unit. The medical entries shall be compiled and stored by a general practitioner (a primary health care internist, a primary health care pediatrist). The medical entries shall be electronically accumulated in a unified electronic information system of the health sector in accordance with the laws and regulations regarding the unified electronic information system of the health sector.

[10 December 2013 / New wording of this Paragraph shall come into force on 1 April 2014.]

6. If a patient changes the general practitioner (the primary health care internist, the primary health care pediatrist), the general practitioner shall transfer the complete medical entries regarding the relevant patient to the general practitioner selected by the patient.

7. The medical entries made regarding a patient in an out-patient medical treatment institution shall form an out-patient medical card of the patient. The medical entries regarding a patient made in an inpatient medical treatment institution shall form the medical history of the patient.

8. The doctor providing medical treatment shall append to the medical entries of a patient information regarding a health care service provided to a patient which is received in other medical treatment institution or which is provided by other medical treatment persons.

9. The medical entries of patients discharged from an inpatient medical treatment institution shall be completed and transferred for storage to a filing cabinet of the inpatient medical treatment institution not later than 14 days after the discharge from the inpatient medical treatment institution. A responsible medical practitioner assigned by the head of the inpatient medical treatment institution shall be responsible for the transfer of the medical entries for storage to the filing cabinet of the inpatient medical treatment institution.

9.¹ The medical entries regarding health care at home shall be completed and transferred for storage to a filing cabinet of the inpatient medical treatment institution within seven days after completion of the home care episode.

[20 September 2011]

III. Content and Protection of the Medical Entries

10. The medical entries shall contain information which ensures recognition of a patient, certifies diagnosis, substantiates examinations and medical treatment methods, and also precisely demonstrates medical treatment results.

[15 April 2008]

11. The medical entries, which are to be competed in an inpatient medical treatment institution, shall also be completed by outpatient medical treatment institutions, if surgical operations or manipulations have been carried out in the outpatient operation ward of the day hospital of the relevant institution.

12. An evolution of the disease shall be entered in the medical entries within 24 hours after the patient's reception in an inpatient medical treatment institution.

13. If additional information regarding any activity related to medical treatment, manipulation and pre-operational time of a patient is obtained or submitted, it shall be added to the medical entries without delay.

14. An opinion on completion of hospitalisation may be replaced by a final entry, which contains information regarding medical treatment results and recommendations, if:

14.1. the patient must be hospitalised for a period of less than 48 hours;

14.2. a healthy child is born in labour and labour has occurred without complications.

14.¹ Epicrisis regarding health care at home shall be completed in two copies, if the health care at home or episode thereof is finished. One copy shall be transferred to the general practitioner of the patient, the other copy shall be appended to the patient's medical card.

[20 September 2011]

15. If the death of a patient has occurred, an opinion on the death and a final entry, in which the reason due to which the patient has been received in a hospital (if a patient has died in the hospital), the results of examinations and medical treatment course, and also reasons of the death shall be provided, shall be added to the medical entries.

16. If an autopsy is carried out after the death of a patient, a pathological anatomical diagnosis shall be appended to the medical entries within three days, but a complete statement shall be appended to the medical entries within 30 days after the autopsy.

17. A summary is one of the parts of the medical entries of the outpatient medical treatment institution. The summary shall contain the following information:

17.1. the final diagnosis;

17.2. information regarding diseases (also infectious diseases) and injuries (according to a patient's words) suffered previously;

17.3. known significant surgical and invasive procedures;

17.4. known adverse and allergic reactions;

17.5. information regarding medicinal products to be used on regular basis.

18. The summary shall be located in an outpatient medical card of a patient at the same place. It shall be completed in the case of the first time illness and in the case of acute condition of a chronic illness, or when a patient visits a medical practitioner for the first time. Hereinafter, medical practitioners shall supplement the summary after the patient's visit. If significant information regarding the patient is also located in another medical entry, the summary shall contain an indication where the relevant information is located. Diagnosis or assessment of the condition must not be indicated repeatedly during one and the same medical treatment.

19. A patient can become familiar with information, which is included in the medical entries regarding him or her and stored in a medical treatment institution, by visiting the doctor providing medical treatment in a medical treatment institution. The duty of the doctor providing medical treatment is to provide information regarding the diagnosis of the patient, examination and treatment plan, regarding other treatment methods and prognosis of the disease included in the medical entries in an understandable way and also to explain the meaning of the content of the entries made in the medical documents.

20. [20 September 2011]

21. If the doctor providing medical treatment or the head of the medical treatment institution has determined, that a part of the medical entries contains information which is to be specially protected, it shall be kept separately on technical information carriers. In such case the place of location of the relevant part of information shall be indicated in the medical entry.

22. The head of the medical treatment institution shall ensure protection of the medical entries and information included therein against deletion, amending of facts and unauthorised use, and shall assign a medical practitioner responsible for the protection of the medical entries and information included therein (hereinafter - the responsible person).

23. Medical practitioners of the medical treatment institution involved in the medical treatment process of a patient shall, during working hours, ensure that persons, which are not involved in the medical treatment process, cannot access the medical entries of the patient and information included therein.

24. Out of the working hours of a medical treatment institution the medical entries of the patient and information included therein shall be stored in a separately locked room or locked cabinets, which do not provide access to persons not involved in treatment process. The keys of the room or cabinets shall be kept by the responsible person.

IV. Quality of the Medical Entries

25. The medical entries shall be true, complete, clearly legible and without corrections.

26. Entries in medical documents may be made only by medical practitioners. Reports regarding examinations carried out for a patient, which are drawn up electronically, shall be signed by the doctor providing medical treatment and they shall be appended to the medical entries. If a medical document is drawn up electronically in conformity with the laws and regulations regarding drawing up electronic documents, the document details "signature", "date" and "stamp" shall not be completed. Only completed sections of the medical documents drawn up electronically may be printed out on a paper.

[15 April 2008; 25 November 2014]

27. In order to certify performance of instructions by the doctor providing medical treatment in the health care of a patient, a medical practitioner shall indicate obvious facts in the medical entries. Entries provided in medical documents by a medical practitioners other than doctors shall be determined in the internal rules of procedures of a medical treatment institution. Symbols and abbreviation may be used only in those cases which are provided for in the internal rules of procedures of a medical treatment institution.

28. Pathomorphological reports, and also description of the operation and epicrisis shall be printed, except for the epicrisis regarding care at home.

[20 September 2011]

29. A medical entry is regarded to be fully completed, if it contains all necessary parts laid down in this Regulation, including epicrisis or final entry, and if all final diagnoses and complications have been entered.

30. If due to justified reasons corrections are to be made in the medical entries, retention of initial information included in the medical entries and adding thereof to the corrections shall be ensured.

V. Medical and Register Documents to be Used in Medical Treatment Institutions and Time Periods for Storage Thereof

[25 November 2014]

31. Inpatient medical treatment institutions shall use the register documents referred to in Annexes 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 15, 18, 19, 20, 22, 23, 24, 26, 28, 29, 30, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 83, 85, 89, 90, 91, 94 and 104 to this Regulation.

[16 February 2016]

32. Outpatient medical treatment institutions shall, according to their profile of activity, use the register documents referred to in Annexes 12, 15, 18, 19, 20, 22, 23, 24, 26, 30, 32, 39, 40, 41, 42, 43, 44, 45, 46, 47, 49, 51, 53, 57, 58, 60, 61, 84, 85, 89, 90, 91, 92, 94, 95, 96, 99, 100, 101, 102 and 103 to this Regulation.

[16 February 2016]

32.¹ An outpatient medical treatment institutions may in conformity with their profile of activity use the register documents referred to in Annex 16 and 93 to this Regulation.

33. Medical treatment institutions other than those referred to in Paragraphs 31 and 32 of this Regulation shall use the register documents which are referred to in Annexes 62, 63, 64, 66, 68 and 85 to this Regulation.

34. Medical treatment institutions shall use the standard medical documents referred to in Annexes 54, 59, 70, 73, 75, 76, 77, 79, 80, 81 and 88 to this Regulation.

34.¹ The medical treatment institution of the National Armed Forces may use the documents referred to in Annex 40 and 100 to this Regulation also outside the territory of Latvia.

[29 September 2015]

35. The medical entries which are provided:

35.1. in the documents referred to in Annexes 5, 10, 15, 18, 24, 28, 29, 39, 40, 41, 53, 63, 75, 83 and 100 to this Regulation shall be stored for one year after the last entry;

35.2. in the documents referred to in Annexes 8, 36 and 37 to this Regulation shall be stored for two years after the last entry;

35.3. in the documents referred to in Annexes 26, 62 and 85 to this Regulation shall be stored for three years after the last entry;

35.4. in the documents referred to in Annexes 4, 7, 9, 11, 23, 32, 38, 42, 45, 46, 51, 58, 60, 66, 68, 79, 80, 81, 82 and 91 to this Regulation shall be stored for five year after the last entry;

35.5. in the documents referred to in Annexes 6, 57, 90 and 99 to this Regulation shall be stored for 10 years after the last entry;

35.6. in the documents referred to in Annexes 1, 13, 19, 20, 22, 43, 44, 59, 76 and 77 to this Regulation shall be stored for 15 years after the last entry;

35.7. in the documents referred to in Annex 61 to this Regulation shall be stored for 25 years after the last entry;

35.8. in the documents referred to in Annexes 2, 3, 30, 34, 35, 47, 49, 64, 70, 73, 84, 93 and 95 to this Regulation shall be stored for 75 years after the last entry;

35.9. in the accompanying check of the document referred to in Annex 64 to this Regulation shall be stored for one year.

[29 September 2015; 16 February 2016]

35.¹ Images obtained by radiological manipulations (in radiodiagnostic films or in electronic form) shall be stored for 10 years.

VI. Closing Provisions

36. Paragraphs 19, 31, 32, 33 and 34 of this Regulation shall come into force on 1 July 2006.

37. Paragraphs 20 and 24 of this Regulation shall come into force on 1 January 2007.

38. The register forms referred to in Annexes 5, 10, 19, 21, 24, 26, 29, 40, 41, 51 and 61 to this Regulation, which have been acquired before 31 December 2011, may be used no longer than until 31 December 2012.

[20 September 2011]

39. The register forms referred to in Annexes 12, 45, 46, 63, 76, 77, 83, 90 and 91 to this Regulation, which have been acquired before 1 January 2014, may be used no longer than until 31 December 2014.

[10 December 2013]

40. The register forms of medical documents referred to in Annexes 32, 40, 41 and 51 to this Regulation, which have been acquired before 1 January 2015, may be used no longer than until 30 June 2015.

[25 November 2014]

41. The register form of a medical document referred to in Annex 40 to this Regulation, which has been received before 1 October 2015, may be used until 1 October 2016.

[29 September 2015]

42. The register forms of medical documents referred to in Annexes 30, 35, 39, 42, 90 and 99 to this Regulation, which have been acquired before 1 March 2016, may be used no longer than until 1 August 2016.

[16 February 2016]

Prime Minister A. Kalvītis

Minister for Health G. Bērziņš

Annex 93
Cabinet Regulation No. 265
4 April 2006

[20 September 2011]

Name of the medical treatment institution
Code

I. Physical and mental development assessment sheet for a child from 1 week to 5 years of age¹

1. Given name, surname
2. Date of the birth (dd.mm.yyyy)		.   .     .
3. Personal identity number       -
4. Gender (mark as appropriate)	1 - male; 2 - female

Weight at the birth _______ g		height ________ cm			head circumference ________ cm
Weight at the discharge ________ g
Labour/Apgar score			Family anamnesis				Risk factors (including genetic)
Child's age	1 week			3 weeks			1 month
Date of the visit	.   .     . (dd.mm.yyyy)			.   .     . (dd.mm.yyyy)			.   .     . (dd.mm.yyyy)
Physical development (in addition see physical development curves in Chapter II, Sub-paragraph 1 or 3, correct, if the child is born before week 37)
Weight (g)	(if possible)			(if possible)
Height (cm)
Head circumference (cm)
Complaints from the parents
Feeding2; 3	Breastfeeding (exclusive) D vitamin 10 micrograms (400-900 IU/per day) Formula 150 ml/kg/d Nature of laxation Passing of urine			Breastfeeding (exclusive) D vitamin 10 micrograms (400-900 IU/per day) Formula 150 ml/kg/d Nature of laxation Passing of urine		Breastfeeding (exclusive) D vitamin 10 micrograms (400-900 IU/per day) Formula 150 ml/kg/d Nature of laxation Passing of urine
Educating and advice2; 3	TRAUMA PREVENTION
	Safety of the baby's bed Sleeping position/bed sharing/sleeping in the parents' room Car seat (infant) Emergency telephone numbers CO/smoke detector Suffocation/safe toys Hot water < 49 °C Safety of weapons
	BEHAVIOUR AND FAMILY ISSUES
	Sleep/crying Assess the necessity to apply for a home visit by a social care provider Eating habits of the mother Brothers and sisters Consolation/sympathy Family conflicts/stress Parental responsibility/upbringing Parent tiredness/depression
	OTHER ISSUES
	Passive smoking Do not use medicinal products against cough/reducing cold symptoms Temperature control/appropriate clothes Ask regarding use of alternative medicine Discuss the use of a teat Sun exposure/sun protection products/insect repellents Fever control
Information to parents3							Immunisation programme Use of antipyretics
Development2; 3 Absence of any feature determines further assessment of the development. Correct, if born before week 37	Sucking reflex Reflector reaction of leg support/automatic stepping When lying on the belly, turns the head from the middle position to the side		Good breast sucking Reflector reaction of leg support/automatic stepping When lying on the belly, turns the head from the middle position to the side Parents have no concerns regarding development of the child				Focuses sight Reacts to a loud or sudden sound Good breast sucking (grip and position of the breast) When lying on the belly, lifts the head Calms down at the feeling of comfort Parents have no concerns regarding development of the child
Clinical examination2; 3 It is recommended to carry out clinical examination appropriate to the age in each visit	Physical examination of all organ systems Special attention: Skin (jaundice, dryness) Fontanelle Red reflex examination of eyes with ophthalmoscope Heart/lungs Navel/liver Femoral pulse Hips External genitals/ testicles Care of foreskin of a boy/urine jet Muscular tonus		Physical examination of all organ systems Special attention: Skin (jaundice, dryness) Fontanelle Heart/lungs Navel/liver Femoral pulse Hips External genitals/testicles Care of foreskin of a boy/urine jet Muscular tonus				Physical examination of all organ systems Special attention: Skin (jaundice) Fontanelle Corneal light reflex Heart Hips Muscular tonus
Problems, plans2; 3; 4; 5	Screening result of phenylketonuria (PKU) and congenital hypothyroidism (CHT) Hearing examination with otoacoustic emissions method - testing result		Red reflex examination of eyes with ophthalmoscope, if it has not been carried out previously Hearing examination with otoacoustic emissions method, if it has not been carried out previously				Red reflex examination of eyes with ophthalmoscope, if it has not been carried out previously Hearing examination with otoacoustic emissions method, if it has not been carried out previously
Health group	1 2 3		1 2 3				1 2 3
Immunisation2	According to vaccination calendar Additional vaccination		According to vaccination calendar Additional vaccination				According to vaccination calendar Additional vaccination
Doctor's signature

Child's age	2 months			3 months		4 months		6 months
Date of the visit (dd.mm.yyyy)	.   .     .			.   .     .		.   .     .		.   .     .
Physical development (in addition see physical development curves in Chapter II, Sub-paragraph 1 or 3, correct, if the child is born before week 37)
Weight (g)								(x 2 birth weight)
Height (cm)
Head circumference (cm)
Complaints from the parents
Feeding2; 3		Breastfeeding (exclusive breastfeeding/mostly breastfeeding/partly breastfeeding) D vitamin 10 micrograms (400-900 IU/per day) Formula		Breastfeeding (exclusive breastfeeding/mostly breastfeeding/partly breastfeeding; discuss causes for hypogalactia) D vitamin 10 micrograms (400-900 IU/per day) Formula		Breastfeeding (exclusive breastfeeding/mostly breastfeeding/partly breastfeeding) D vitamin 10 micrograms (400-900 IU/per day) Formula		Breastfeeding D vitamin 10 micrograms (400-900 IU/per day) Formula Exclude food allergies Fruit/vegetables Assess necessity of food containing iron (cereal, meat) Do not give egg white, nuts, honey Do not give sweetened liquids Do not give a bottle in the bed Safe food (choking prevention)
Educating, advice2; 3		TRAUMA PREVENTION
		Car seat (infant) Sleeping position/bed sharing/sleeping in the parents' room/safety of a bed Poisons/emergency telephone numbers Electrical switches/sockets CO/smoke detectors Suffocation/safe toys Safety of weapons Hot water < 49 °C/bathtub safety Falling (stairs, baby walkers, baby changing table)
		BEHAVIOUR AND FAMILY ISSUES
		Sleep/crying/waking up at night  Parental responsibility/upbringing Assess the necessity to apply for a home visit by a social care provider Consolation/sympathy Parent tiredness/depression Family conflicts/stress Brothers and sisters Returning at work/necessity of a nanny
		OTHER ISSUES
		Passive smoking  Teething/teeth care/fluorine  Fever control Temperature control/appropriate clothes Food quality (pesticides) Discuss the use of a teat Sun exposure/sun protection products/insect repellents Ask regarding use of alternative medicine Do not use medicinal products against cough/reducing cold symptoms Read aloud
Information to parents3					Immunisation programme Use of antipyretics
Development2; 3 Absence of any feature determines further assessment of the development. Correct, if born before week 37		Follows to a movement with eyes Makes sounds and crows ("chats" or intonative screaming) When applied to a shoulder of an adult, holds the head Likes touches and cuddles Replies with a smile When eating two or several sucking episodes before swallowing Parents have no concerns regarding development of the child	With eyes and turning the head above centre line, follows to a movement "Social smile" The first strings of syllables Is stable when supporting on forearms Parents have no concerns regarding development of the child		Laughs/shrieks in a dialogue with parents Answers to people with excitement Holds stable his or her head, if he or she is supported on a shoulder or put in a seating position Accepts position on the belly Makes rhythmic strings of syllables (sounds) Holds a subject for a short time period, if it is put in a hand Follows moving toy or person with eyes Parents have no concerns regarding development of the child		Turns his or her head to the direction of a sound Follows a moving object Babbling/makes syllables in different sound volume, tonality Shows joy or dislike with his or her voice Replies with a voice when somebody speaks with him or her Support on opened palms in the position on the belly Rolls from back to belly and vice versa Sits with a support Reaches/grasps toys Parents have no concerns regarding development of the child
Clinical examination2; 3 It is recommended to carry out clinical examination appropriate to the age in each visit		Physical examination of all organ systems Special attention: Fontanelle Heart Hips Muscular tonus	Physical examination of all organ systems Special attention: Fontanelle Red reflex examination of eyes with ophthalmoscope Light reflex of cornea Ask about hearing Heart Hips Muscular tonus		Physical examination of all organ systems Special attention: Fontanelle Ask about hearing Hips Muscular tonus		Physical examination of all organ systems Special attention: Fontanelle Red reflex examination of eyes with ophthalmoscope Corneal light reflex/examination of strabismus with cover test Ask about hearing Hips Muscular tonus
Problems, plans2; 3		Red reflex examination of eyes with ophthalmoscope, if it has not been carried out previously Corneal light reflex examination, if it has not been carried out previously Hearing examination with otoacoustic emissions method, if it has not been carried out previously			Red reflex examination of eyes with ophthalmoscope, if it has not been carried out at 3 months of age Corneal light reflex examination, if it has not been carried out at 3 months of age
Health group		1 2 3	1 2 3		1 2 3		1 2 3
Immunisation3		According to vaccination calendar Additional vaccination	According to vaccination calendar Additional vaccination		According to vaccination calendar Additional vaccination		According to vaccination calendar Additional vaccination
Doctor's signature

Child's age

9 months (additional check-up from 7 to 11 months)

12 months

15 months

Date of the visit (dd.mm.yyyy)

.   .     .   .   .     .

.   .     .

.   .     .

Physical development (in addition see physical development curves in Chapter II, Sub-paragraph 1 or 3, correct, if the child is born before week 37)

Weight (g)

(x 3 birth weight)

Height (cm)

Head circumference (cm)

(approximately 47 cm)

Complaints from the parents

Feeding2; 3

Breastfeeding D vitamin 10 micrograms (400-900 IU/per day) Formula Do not give a bottle in the bed Do not give sweetened beverages Cereal, fruit, vegetables, meat/alternatives Getting familiar with cow's milk products Do not give egg white, nuts, honey Safe food (choking prevention)

Breastfeeding D vitamin 10 micrograms (400-900 IU/per day) Formula or 2 % cow milk Encourage to use a cup instead of a bottle Lower appetite Safe food (choking prevention)

Breastfeeding D vitamin 10 micrograms (400-900 IU/per day) Formula or 2 % cow milk Encourage to use a cup instead of a bottle Safe food (choking prevention)

Educating and advice2; 3

TRAUMA PREVENTION

Car seat (infant/child) Poisons/emergency telephone number Safety of weapons CO/smoke detectors Electrical switches/sockets Suffocation/safe toys Hot water < 49°C/bathtub safety Falling (stairs, baby walkers)

BEHAVIOUR AND FAMILY ISSUES

Sleep/crying/waking up at night  Parental responsibility/upbringing Assess the necessity to apply for a home visit by a social care provider Consolation/sympathy Parent tiredness/depression Family conflicts/stress Brothers and sisters Necessity of a kindergarten/babysitter

OTHER ISSUES

Passive smoking  Teething/teeth care/fluorine/dentist  Fever control Food quality (pesticides) Discuss the use of a teat Sun exposure/sun protection products/insect repellents Ask regarding use of alternative medicine Environment (lead) Footwear Active and healthy lifestyle/environment Do not use medicinal products against cough/reducing cold symptoms Read aloud

Information to parents

Development2; 3 Absence of any feature determines further assessment of the development. Correct, if born before week 37

Seeks after hidden toys Uses clear double-syllables Reacts differently to different people Uses sounds to pay attention to himself or herself Sits without a support Stands with holding on to something Plays social games (touches his or her nose) Reaches to be hold up Puts thumb and pointing finger together Parents have no concerns regarding development of the child

Responds to his or her name Understands simple instructions First words or syllables with a meaning Tries to pronounce 3 or more words (may be unclear) Crawls or slips Stands up/stands freely Walks with holding on something Shows emotions according to a situation Grasps a tiny object with a thumb and bent pointing finger Reacts painfully to parting from parents/carer Parents have no concerns regarding development of the child

Tries to pronounce 5 or more words (may be unclear) Tries to obtain something with help of sounds or gestures Grasps and eats with fingers Crawls some steps up the stairs Shows fear from strange people/places Tries to squat to take a toy from the floor Takes off socks, tries to open shoelaces Makes a pyramid of two blocks Watches the reaction of adults in order to understand how to react (when falling down himself or herself) Parents have no concerns regarding development of the child

Clinical examination2; 3 It is recommended to carry out clinical examination appropriate to the age in each visit

Physical examination of all organ systems Special attention: Fontanelle Ask about hearing Hips

Physical examination of all organ systems Special attention: Fontanelle Ask about hearing Size of tonsils/teeth Hips

Physical examination of all organ systems Special attention: Fontanelle Ask about hearing Size of tonsils/teeth Hips

Problems, plans2; 3

Red reflex examination of eyes with ophthalmoscope, if it has not been carried out at 6 months of age Corneal light reflex/ examination of strabismus with cover test, if it has not been carried out at 6 months of age

Haemoglobin concentration in blood

Examination by an oculist (once in 13-24 months of age) Red reflex examination of eyes with ophthalmoscope, if examination by an oculist has not been carried out Corneal light reflex/examination of strabismus with cover test, if examination by an oculist has not been carried out

Health group

1 2 3

1 2 3

1 2 3

Immunisation3

According to vaccination calendar Additional vaccination

According to vaccination calendar Additional vaccination

According to vaccination calendar Additional vaccination

Doctor's signature

Child's age	18 months	2 years	3 years	4 years	5 years
Date of the visit	.   .     . (dd.mm.yyyy)	.   .     . (dd.mm.yyyy)	.   .     . (dd.mm.yyyy)	.   .     . (dd.mm.yyyy)	.   .     . (dd.mm.yyyy)
Physical development (in addition see physical development curves in Chapter II, Sub-paragraph 1 or 3, but starting from 2 years of age - Sub-paragraph 2 or 4, correct, if the child is born before week 37, until 2-3 years of age)
Weight (g)
Height (cm)
Head circumference (cm)		(if was not normal)
Complaints from the parents
Feeding2; 3	Breastfeeding D vitamin 10 micrograms (400-900 IU/per day) Formula or 2 % cow milk Feed not using a bottle	D vitamin 10 micrograms (400-900 IU/per day) Formula or 2 % cow milk Feeding recommendations Gradual transition to food with a lower fat content		2 % milk Feeding recommendations

Educating and advice2; 3	TRAUMA PREVENTION
	Car seat (child) Bathtub safety  Suffocation/safe toys	Car seat (child) Protective helmet/protectors Emergency telephone number CO/smoke detectors Safety-matches Safety on water Safety of weapons
	BEHAVIOUR AND FAMILY ISSUES
	Parent/children contact Discipline/restrictions  Parent tiredness/stress/depression High social risk child	Parent/children contact Discipline/restrictions Parent tiredness/stress/depression High social risk child Brothers and sisters Family conflicts
	OTHER ISSUES
	Socialisation/role games Teeth care/dentist Learning to use a toilet/hygiene Break using of a teat Read aloud	Teeth care/fluorine/dentist  Ask regarding use of alternative medicine Active and healthy lifestyle/environment Passive smoking Learning to use a toilet/hygiene Assess readiness for pre-school institution/school Socialisation possibilities Sun exposure/sun protection products/insect repellents Food quality (pesticides) Environment (lead) Do not use teat Do not use medicinal products against cough/reducing cold symptoms Read aloud
Information to parents
Development2; 3 Absence of any feature determines further assessment of the development. Correct, if born before week 37	Usually the child's behaviour can be controlled easily He or she has interest about other children Usually he or she can be calmed down easily Seeks for support when in sorrow Indicates to several different body parts Tries to attract attention in order to show something Turns when his or her name is called Indicates to something he or she wants Seeks a toy when he or she is asked to do it Imitates speech sounds knowingly Pronounces 20 or more words (may be unclear) Can say three different consonants Walks freely Eats with a spoon unaided Takes off a bonnet/socks unaided Parents have no concerns regarding development of the child	2 years At least one new word per week Two-word sentences Understands one or two-stage instructions (take the small ball and give to mummy) Makes two steps backwards without a support Tries to run Puts an object in a small container Imitates his or her parents (gives a doll to drink) Continues to acquire new skills Parents have no concerns regarding development of the child	4 years Understands related directions to three sides Asks many questions and replies (what are you doing?) Uses simple compound sentences Stands on one leg 1-3 sec. Goes up the stairs by alternating feet Draws people with at least three body parts Uses the toilet during the day Opens buttons and zip-fastener Tries to calm down somebody who is sad Parents have no concerns regarding development of the child
		3 years Understands two-stage and three-stage instructions (take the hat and shoes and put them in the wardrobe) Uses sentences with 5 or more words Goes up the stairs with adding step, by holding to handrails Twists off lids from dishes/turns switches Plays behaviour games with actions and words (pretends that he or she is cooking, repairing a car) Spends a short period of time together with known people without parents/carer Turns over book pages one by one Imitates writing movements Draws a circle Listens to music or stories for 5-10 min. together with an adult Parents have no concerns regarding development of the child	5 years Counts aloud or on fingers in order to answer "how many?" Knows basic colours and forms Speaks clearly for the most part of the time Uses complex sentences Throws and catches a ball Is engaged with one activity for 20-30 min. alone Can dress himself or herself with minimum assistance Shares willingly Hops on one leg Retells episodes of a story Easily parts from parents/carer Parents have no concerns regarding development of the child
Clinical examination2; 3 It is recommended to carry out clinical examination appropriate to the age in each visit	Physical examination of all organ systems Special attention: Fontanelles are closed Ask about hearing Size of tonsils/teeth	Physical examination of all organ systems Special attention: Red reflex examination of eyes with ophthalmoscope/vision sharpness Corneal light reflex/examination of strabismus with cover test Ask about hearing Size of tonsils/teeth Blood pressure	Physical examination of all organ systems Special attention: Ask about hearing Size of tonsils/teeth Blood pressure
Problems, plans2; 3	Examination by an oculist, if it has not been carried out previously Red reflex examination of eyes with ophthalmoscope, if examination by an oculist has not been carried out Corneal light reflex/examination of strabismus with cover test, if examination by an oculist has not been carried out	Examination by an oculist at 3 years of age Dental hygienist at 2 years of age Dental hygienist at 3 years of age Consultation of a speech therapist/audio speech therapist, where necessary	Dental hygienist at 4 years of age Dental hygienist at 5 years of age Red reflex examination of eyes with ophthalmoscope/vision sharpness, if examination by an oculist has not been carried out at 3 years of age Corneal light reflex/examination of strabismus with cover test, if examination by an oculist has not been carried out at 3 years of age Consultation of a speech therapist/audio speech therapist, where necessary
Health group	1 2 3	1 2 3	1 2 3
Immunisation3	According to vaccination calendar Additional vaccination	According to vaccination calendar Additional vaccination	According to vaccination calendar Additional vaccination
Doctor's signature

Notes.

¹ Adapted, by using Leslie Rourke, Denis Leduc and James Rourke "Rourke Baby Record" of May, 2006, and August, 2009.

² Degree of evidence: in bold - proved good; italic - proved on average; standard - without evidence, but there is a consensus (agreement) by specialists.

³ Designations when completing a card: √ - no problem, X - a problem.

⁴ Screening of phenylketonuria (PKU) and congenital hypothyroidism (CHT) shall be carried out on 4th-5th day of life.

⁵ Hearing examination with otoacoustic emissions method shall be carried out on 3rd-4th day of life. Pay attention to children who are born in planned out-of-hospital labour, because examination of children born in a hospital is carried out in a labour ward.

II. Norms of physical development of children

1. Percentile card of girls' head circumference, body height and body weight from the birth until 24 months of age

2. Percentile card of girls' body height, body weight and BMI from 2 until 18 years of age

3. Percentile card of boys' head circumference, body height and body weight from the birth until 24 months of age

4. Percentile card of boys' body height, body weight and BMI from 2 to 18 years of age

Translation © 2017 Valsts valodas centrs (State Language Centre)