Compositional and substantial structure of the medical document: formation stages

The article deals with the compositional and substantial structure of the ambulatory medical record, or "case history", which has being formed for a long time. The author allocates the three main periods in the formation of this medical document: the first period (the beginning of the 19th century - 1920s) is connected with the origin and formation; the second period (1920-1980s) is marked by emergence of the normative legal acts regulating registration and maintaining; the third period (1980s - up to the present) is associated with the cancellation of regulations and the introduction of the new order of the Ministry of Health of the USSR that changed the document's form and name. It is determined that the composition of the case history consists of the title page and the main part. The following processes take place in the course of ambulatory medical record's formation: strengthening formalization, increase in the number of pattern text fragments, increase in the text's volume, and the implementation of bigger number of functions. The author reveals the main (informative and cumulative, accounting) and additional (scientific, controlling, legal, financial) functions of the document. The implementation of these functions is reflected in the compositional and substantial structure of the document text and is conditioned by a number of extralinguistic factors.