Order 330 of 05.08 03. Program Center "Aid to Education". Eating disorders assessment

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

With changes and additions from:

On 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-VS

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 Decree of the Government of the Russian Federation dated 10.08.1998 N 917 *, to improve the organization of medical nutrition and increase the effectiveness of its application in the complex treatment of patients, I order:

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

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

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

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

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

2. Control over the implementation of this order shall be entrusted to the Deputy Minister RA Khalfin.

Order 330 on nutritional therapy

MINISTRY OF HEALTH OF THE RUSSIAN FEDERATION

ABOUT IMPROVEMENT MEASURES
MEDICAL NUTRITION IN MEDICAL 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 *, to improve the organization of medical nutrition and increase the effectiveness of its application in the complex treatment of patients, I order:

———————————
* Collected Legislation of the Russian Federation, 08.24.1998, No. 8, Art. 4083.

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

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

The minister
Yu.L. Shevchenko

Appendix No. 1
Approved by
By order of the Ministry
health care
Russian Federation
dated 05.08.2003 No. 330

POSITION
ABOUT THE ORGANIZATION OF ACTIVITIES OF THE DIET STUDENT

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

The dietitian is responsible for the organization of nutritional therapy and its adequate application in all departments of health care institutions.

A dietitian doctor supervises dietary nurses, supervises the work of the catering department.

The dietitian is obliged to:

advise department doctors on the organization of medical nutrition;

to advise patients on the issues of therapeutic and rational nutrition;

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

analyze the effectiveness of medical nutrition;

to monitor the correctness of the bookmark of products when preparing dishes;

prepare documentation for the organization of medical nutrition:
- layout cards;
- seven-day menu;
- seven-day consolidated menu - summer and winter options;

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

monitor the quality of finished 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 food parcels at home for a patient being treated in a medical and prophylactic institution;

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

to organize systematically the improvement of the level of qualification of the catering department workers on the issues of medical nutrition;

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

to raise the level of professional qualifications in the cycles of improvement in dietetics at least once every 5 years.

Appendix No. 2
Approved by
By order of the Ministry
health care
Russian Federation
dated 05.08.2003 No. 330

POSITION
ABOUT ORGANIZATION OF MEDICAL ACTIVITIES
DIETARY SISTERS

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

A dietary nurse works under the guidance of a dietitian.

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

A dietary nurse is obliged:

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

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

to monitor the correctness of the laying of products during cooking and waste finished products, take a sample of finished food;

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

monitor: for sanitary condition the premises of the catering unit, distribution rooms, pantries, inventory, dishes, as well as the implementation of the rules of personal hygiene by the employees of the catering unit;

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

keep medical records;

carry out timely preventive medical examinations of employees of the catering department, dispensers and canteens and prevent persons who have not undergone a preventive medical examination and patients with pustular, intestinal diseases, angina from working;

to raise the level of professional training at least once every 5 years.

Appendix No. 3
Approved by
By order of the Ministry
health care
Russian Federation
dated 05.08.2003 No. 330

POSITION
ABOUT THE ADVICE ON HEALING NUTRITION
MEDICAL AND PREVENTIVE INSTITUTIONS

(as amended by the Order of the Ministry of Health and Social Development of the Russian Federation of 26.04.2006 No. 316)

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

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

The composition of the Council for Curative Nutrition includes: the chief physician (or his deputy for medical work) - the chairman; nutritionist - executive secretary, heads of departments - doctors, 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 and prophylactic institution may be involved in the work of the Council.

The objectives of the Nutritional Health Council:

improvement of the organization of medical nutrition in a medical and prophylactic institution;
introduction of new technologies for preventive, dietary and enteral nutrition;
approval of the nomenclature of diets, mixtures for enteral nutrition, protein composite dry 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 of 26.04.2006 No. 316)
approval of seven-day menus, a card index of meals and a set of mixtures for enteral nutrition;
improvement of the ordering system for dietary kits and mixtures for enteral nutrition;
development of forms and plans for professional development of employees in therapeutic nutrition;
control over the organization of medical nutrition and analysis of the effectiveness of diet therapy for various diseases.
The Nutritional Health Council meets as needed, but at least once every three months.

Appendix No. 4
Approved by
By order of the Ministry
health care
Russian Federation
dated 05.08.2003 N 330

INSTRUCTION
ON ORGANIZATION OF MEDICAL NUTRITION
IN MEDICAL AND PREVENTIVE INSTITUTIONS

as amended by 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)

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

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

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

surgical diets (0-I; 0-II; 0-III; 0-IV; diet for ulcerative bleeding, diet for stomach stenosis), etc.;
specialized diets: a high-protein diet with active tuberculosis (hereinafter referred to as a high-protein diet (t));
(the paragraph was introduced by the Order of the Ministry of Health and Social Development of the Russian Federation of 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 and dietary therapy, vegetarian diet, etc.).

The individualization of the chemical composition and calorie content of standard diets is carried out by selecting the medical nutrition dishes available in the card index, increasing or decreasing the number of buffet products (bread, sugar, butter), controlling home food parcels for patients undergoing treatment in a medical institution, as well as by use of biologically active food supplements and ready-made specialized mixtures in medical and enteral nutrition. To correct the diet, 20-50% 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 of January 10, 2006 No. 2)

Note:
The order of the Ministry of Finance of the Russian Federation of December 21, 2005 No. 152n became invalid on January 1, 2007 in connection with the publication of the Order of the Ministry of Finance of the Russian Federation of December 8, 2006 No. 168n. The current Instructions on the procedure for applying the budgetary classification of the Russian Federation were approved by Order of the Ministry of Finance of the Russian Federation of December 25, 2008 No. 145n.

The purchase of dry protein composite mixtures for therapeutic nutrition is carried out in accordance with the Instructions on the procedure for applying the budget classification of the Russian Federation, approved by Order of the Ministry of Finance of the Russian Federation No. 152n dated December 21, 2005 (in accordance with the letter of the Ministry of Justice of the Russian Federation dated January 10, 2006 No. N 01/32-ЕЗ Order b state registration does not need) under article 340 economic classification expenses of the budgets of the Russian Federation "Increase in the cost of inventories" with the attribution of ready-made specialized mixtures for medical nutrition to the section "food (payment for food), including food rations for military personnel and persons equated to them."
(the paragraph was introduced by the Order of the Ministry of Health and Social Development of the Russian Federation of April 26, 2006 No. 316)

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

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

The control of the correctness of the diet therapy should be carried out by checking the compliance of the diets received by patients (in terms of the 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 and preventive institution is carried out by the chief physician, and in his absence - by the deputy for the medical part.

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

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

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

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

Table 1
to the Instructions for organizing
prevention facilities

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

www.santegra.spb.ru

By order of the Ministry of Health of Russia, the norms of medical nutrition are approved

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

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

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

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

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

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

The draft order was publicly discussed on the Unified Portal for Disclosure of Information on the preparation by federal executive bodies of draft normative legal acts and the results of their public discussion. There were no comments or suggestions to 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 21.11.2011 No. 323-FZ "On the Basics of Health Protection of Citizens in the Russian Federation" defines the norms governing the foundations of the organization of medical nutrition.

Organization of medical nutrition at the federal level

Organization of medical nutrition at federal level occurs in accordance with the requirements of the following regulations:

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

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

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

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

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

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

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

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

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

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

Federal Departmental Order of the Ministry of Health of the USSR of 05.05.1983 No. 530 "On approval of instructions for accounting for food products in medical and preventive and other health care institutions funded by the state budget of the USSR"(as amended on 05/17/1984, 12/30/1987) and the Order of the Ministry of Health of Russia dated 05/08/2003 No. 330 "On measures to improve medical nutrition in medical institutions of the Russian Federation" approved the system of accounting and document management. It is necessary to maintain documentation in accordance with the requirements of these orders, since it is not only a system for recording patients supplied to meals, but also a system for spending food, monitoring the spending of financial resources.

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

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

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

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

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

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

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

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

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

The main document in this group is a card index of dietary dishes (see the details of this document in the article "Specialized card index of dietary meals", PD No. 1, or on the website www.praktik-dietolog.ru in the section "To the taste of the patient"). Without a card index, it is impossible to correctly compose a seven-day menu, a layout menu, that is, documents that provide information on satisfying the physiological needs of the human body for nutrients and energy, taking into account the mechanisms of the development of the disease, the characteristics of the course of the main and concomitant diseases. The file is of particular importance in correct organization medical nutrition. If it is available, you can calculate what the patient actually gets during the day, plan the work of the catering unit, facilitate organizational measures, calculate the consumption of food and the appropriations allocated for them.

Seven-day summary menu

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

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

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

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

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

Layout card

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

Each layout card contains the following data: the name of the dish, the list of diets for which this dish is recommended to be used; a list of products 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.

Nomenclature of diets

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

Special diets are assigned to a specific clinical and statistical group of patients, the condition of which requires the exclusion of certain food products from the therapeutic diet; they 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 protein composite dry mixtures.

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

Accounting and reporting documentation

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

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

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

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

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

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

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

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

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

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

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

Each of the employees of the catering unit must have:

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

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

Diet service organization documentation (production documentation):

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

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

The need for GOSTs

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

Federal Law of December 27, 2002 No. 184-FZ "On Technical Regulation" defined the principles of standardization in the Russian Federation, established the rules for the application of technical regulations and national standards of the Russian Federation (GOST R 1.0-2004 "Standardization in the Russian Federation. Basic Provisions"). This document states that technical regulations, i.e. federal laws establishing safety requirements, are mandatory to apply 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 “Dietary (therapeutic and prophylactic) food products. Dry protein composite mixtures. General technical conditions ", approved by order Federal agency on technical regulation and metrology of 7.09.2010 No. 219-st, defined the basic requirements for specialized products intended for dietary (therapeutic and prophylactic) nutrition of adults and children over three years old as a protein component for preparing ready-made meals.

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SanPiNs and regulations

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

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

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

Federal Law of December 27, 2002 No. 184-FZ "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 regulations - a document that is adopted by an international treaty of the Russian Federation, subject to ratification in the manner established by law Of the Russian Federation, or in accordance with an international treaty of the Russian Federation, ratified in accordance with the procedure established by the legislation of the Russian Federation, or federal law, or a decree of the President of the Russian Federation, or a resolution of the Government of the Russian Federation, or a regulatory legal act federal body executive power on technical regulation, and establishes mandatory requirements for the application and execution of the objects of technical regulation (products or products and related to product requirements processes of design [including survey], production, construction, installation, adjustment, operation, storage, transportation, implementation and disposal) ".

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

At the level of a constituent entity of the Federation

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

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

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

For the implementation of the specified regulatory legal acts established by the government of the Russian Federation, as well as orders established by the Ministry of Health and Social Development of Russia, and in order to unify the requirements for the organization of dietary (therapeutic and prophylactic) nutrition, standardization of average daily food sets and a seven-day menu in medical organizations in Moscow, the Department Healthcare of the city of Moscow, Order No. 1851 of 23.12.2011 "On improving the organization of dietary (therapeutic and preventive) nutrition" was issued, as well as a number of methodological recommendations "Card file of dietary (medical and preventive) nutrition with an optimized composition for children", which regulates the algorithm for organizing dietary (medical 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 development of the Research Institute of Nutrition of the Russian Academy of Medical Sciences, optimized average daily sets of products are given. Thanks to the measures taken, the unification of requirements for the organization of dietary (therapeutic and prophylactic) nutrition, the standardization of average daily food sets and a seven-day menu in medical organizations in Moscow, heads of medical institutions can reasonably and effectively spend financial resources. In addition, it became necessary to introduce into the work of the health department non-departmental control over the spending of funds for medical nutrition and the quality of diet in medical institutions.

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

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

Clinical features of the disease:
- clinical and statistical group of the disease;
- stage (phase) of the disease of a particular patient;
- a certain clinical situation;
- existing complications of the disease.

Physical indicators of the ratio of the patient's weight and body, the severity of protein-energy deficiency:

the degree of violation of the nutritional status;
body mass index.
Individual characteristics of the organism;
- food intolerance;
- the presence of contraindications to the use of a number of food products in the diet;
- the possibility of taking food products per os, the presence of a gastrostomy, enterostomy.
The process of standardization in dietetics means such actions as setting rules and characteristics for the purpose of their repeated use, aimed at achieving orderliness in the work of the catering units of medical and preventive institutions, preparing dietary meals, prescribing and choosing the type of therapeutic diet and the quality of the medical food provided to the patient.

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

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

technologies for organizing food in medical institutions: types, production processes, food products used for a particular type of food;
technical support for the implementation of dietary nutritional diets;
quality of food;
qualifications of medical personnel involved in catering;
production, terms of sale, quality of food;
accounting and reporting documentation used in the dietetics system;
economic aspects of standardization, food procurement system, personalized accounting.

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

At the healthcare facility level

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

At the same time, when organizing medical nutrition directly in a medical institution, various types of medical 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 technique of execution.

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

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

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

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

Enteral and parenteral nutrition refers to artificial types of nutrition that are used only for medical reasons when it is impossible to adequately meet the energy and plastic needs of the body in a natural way in a number of diseases and are presented in a number of reference books and recommendations for carrying out nutritional support in intensive care and resuscitation. These sections are not within the competence of a 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 intake 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 organizational standards into the work of medical institutions:

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

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

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

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

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

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

Organization of medical nutrition at the federal level

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

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

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

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

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

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

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

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

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

Normative legal document	Nutritional standards
Order of the Ministry of Health of Russia dated 5.08.2003 No. 330 "On measures to improve therapeutic nutrition in medical and preventive institutions of the Russian Federation" (registered with the Ministry of Justice of Russia 12.09.2003 No. 5073) as amended by orders of the Ministry of Health and Social Development of Russia dated 7.10.2005 No. 624 (registered in the Ministry of Justice of Russia on November 1, 2005, No. 7134), dated January 10, 2006, No. 2 (registered in the RF Ministry of Justice 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).	Average daily set of products for one patient in medical institutions. Average daily food sets for children undergoing treatment in sanatorium-resort institutions of various profiles (except for tuberculosis). Average daily set of products for adults undergoing sanatorium treatment. Average daily food packages for children affected by radiation exposure, being treated in sanatorium-resort institutions of various profiles (except for tuberculosis).
Order of the USSR Ministry of Health of 03/10/1986 No. 333 "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 revised nutritional norms for patients have been agreed with the USSR Ministry of Finance (letter from the USSR Ministry of Finance dated 12.09.85 No. 23-2-10 / 11).	The food norm for patients in maternity hospitals (departments) and children's hospitals (departments) per patient per day in grams.
Order of the Ministry of Healthcare 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 being treated in hospitals (departments of multidisciplinary hospitals) for war veterans.
Orders of the Ministry of Health of the USSR No. 530 of 05.05.1983 “On Approval of Instructions for the Accounting of Food Products in Medical and Prophylactic and Other Healthcare Institutions Funded by the State Budget of the USSR” (as amended on 05.17.1984, 12.30.1987).	Unified food accounting system in a medical institution.

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

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

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

Seven-day summary menu

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

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

Layout card

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

Nomenclature of diets

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

Accounting and reporting documentation

A number of documents that must be kept in a medical institution without fail refer to accounting and reporting documents. At present, in medical institutions, in order to optimize work, automated workflow systems are being introduced, which ensure the introduction of scientifically grounded principles of dietetics.

The main legal document on the basis of which food products are issued from the warehouse to the food processing unit for cooking and the 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 employee, who calculates the total amount of all products required to prepare all the dishes for their discharge from the warehouse.

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

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

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

Each of the employees of the catering unit must have:

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

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

Diet service organization documentation (production documentation):

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

The need for GOSTs

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

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

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

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SanPiNs and regulations

Resolution of the Chief State Sanitary Doctor of the Russian Federation of 05.05.2003 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 January 17, 2005, as amended on June 27, 2008) "Organization of baby food", 2.3.2 "Food raw materials and food products".
Sanitary and epidemiological rules and standards SanPiN2.3.2.1324-03 "Hygienic requirements for shelf life and storage conditions of food".
Resolution of the Chief State Sanitary Doctor of the Russian Federation of March 5, 2004 No. 9 "On additional measures to prevent diseases caused by micronutrient deficiency."

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

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

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

At the level of a constituent entity of the Federation

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

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

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

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

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

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

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

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

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

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

Regional bodies state power RF	Document
Ministry of Health of the Orenburg Region	Order No. 338 of 12/30/2010. Information letter No. 11- l-49/1594 dated 01.12.2008.
Ministry of Health and Social Development of the Chuvash Republic	Information letter No. 03 / 19-7658 dated 27.07.2012.
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 medical nutrition in medical institutions". 2. Order of the Ministry of Health of the Republic of Belarus dated 20.12.2010 No. 2813-D "On the recommended average daily food sets for one patient undergoing inpatient treatment in medical institutions of the Republic of Bashkortostan."
Ministry of Health Chelyabinsk region	Order of the Ministry of Health of the Chelyabinsk Region No. 1155 of 23.10.2009 "On the approval of the clinical and organizational guidelines for doctors to provide medical care to the population of the Chelyabinsk Region."

At the healthcare facility level

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

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

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

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

List of works	Implementation activities
Preparation of regulatory documents for catering	Preparation of an order for the organization of dietary meals. Organization of the work of the Council for Medical 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 on the provision and renovation of 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

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

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

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

Currently, in most medical institutions of the Russian Federation, the technology of protein correction of therapeutic diets has been introduced in order to increase the nutritional and biological value of diets. Dietitians 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 be included in dietary meals during protein correction? The answer to this question is quite simple: the selected products must comply with the requirements of GOST R 53861-2010, and there must be appropriate certification and quality documents for it.

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

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

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

Currently, within the framework of the Unified Sanitary Rules of the EurAsEC Customs Union, specialized food products are defined as subject to mandatory state registration, including baby food, food for pregnant and lactating women, dietary (therapeutic and prophylactic) food, food for athletes. Among the documents of the customs union that regulate the issues of specialized food, the Decision of the Customs Union Commission dated May 28, 2010 No. 299 "On the application of sanitary measures in customs union», Which determined the list of specialized products for the medical nutrition of children.

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

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

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

MINISTRY OF HEALTH
Khabarovsk Territory

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

I declare:

1. .

I order:

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

Ministry of Health of the Russian Federation

On measures to improve
therapeutic nutrition in therapeutic and prophylactic
institutions of the Russian Federation

dated 07.10.2005 No. 624, dated 10.01.2006 No. 2, dated 26.04.2006 No. 316,
Order of the Ministry of Health of Russia dated June 21, 2013 No. 395n,
NSRikaza of the Ministry of Health of Russia dated November 24, 2016 No. 901n)

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 Decree of the Government of the Russian Federation dated 10.08.1998 N 917, to improve the organization of medical nutrition and increase the effectiveness of its application in the complex treatment of patients, I order:

1. To approve:

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

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

1.3. Regulation on the Council for Medical Nutrition (Appendix No. 3);

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

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

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

The minister
Yu.L. Shevchenko

A comment

On the application of this order, see the letter of April 7, 2004 N 2510 / 2877-04-32 and the letter of social development of the Russian Federation of July 11, 2005 N 3237-VS

Appendix N 1

Approved by
By order of the Ministry
health care
Russian Federation
dated 05.08.2003 N 330

POSITION

ABOUT THE ORGANIZATION OF ACTIVITIES OF THE DIET STUDENT

1. A specialist doctor is appointed to the position of a dietitian, having training in therapeutic nutrition and a certificate in the specialty "dietetics".

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

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

4. The dietitian must:

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

b) advise patients on therapeutic and rational nutrition;

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

d) analyze the effectiveness of therapeutic nutrition;

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

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

g) prepare documentation for the organization of medical nutrition:

Layout cards;

Seven-day menu;

Seven-day consolidated menu - summer and winter options;

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

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

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

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

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

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

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

Appendix N 2

Approved by
By order of the Ministry
health care
Russian Federation
dated 05.08.2003 N 330

POSITION

ABOUT ORGANIZATION OF MEDICAL ACTIVITIES

DIETARY SISTERS

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

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

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

4. A dietetic nurse is obliged to:

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

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

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

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

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

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

g) keep medical records;

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

i) improve the level of professional training at least once every 5 years.

Appendix N 3

Approved by
By order of the Ministry
health care
Russian Federation
dated 05.08.2003 N 330

POSITION

ABOUT THE ADVICE ON HEALING NUTRITION

MEDICAL AND PREVENTIVE INSTITUTIONS

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

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

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

4. Tasks of the Nutritional Health Council:

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

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

d) approval of the nomenclature of diets, mixtures for enteral nutrition, protein composite dry mixtures for 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 Russia of 26.04.2006 N 316)

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

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

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

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

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

Appendix N 4

Approved by
By order of the Ministry
health care
Russian Federation
dated 05.08.2003 N 330

INSTRUCTION

ON ORGANIZATION OF MEDICAL NUTRITION

IN MEDICAL AND PREVENTIVE INSTITUTIONS

(as amended by the Orders of the Ministry of Health and Social Development of Russia
from 07.10.2005 N 624, from 10.01.2006 N 2, from 26.04.2006 N 316,
Order of the Ministry of Health of Russia dated 06.21.2013 N 395n)

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

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

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

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

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

Specialized diets: high-protein diet for active tuberculosis (hereinafter - high-protein diet (t));

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 and dietary therapy, vegetarian diet, etc.).

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

(as amended by the Order of the Ministry of Health and Social Development of Russia of 10.01.2006 N 2)

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

(the paragraph was introduced by the Order of the Ministry of Health and Social Development of Russia of April 26, 2006 N 316)

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

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

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

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

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

Table 1

Characteristic,
chemical composition and energy value
standard diets used in hospitals
(in hospitals, etc.)

(as amended by the Order of the Ministry of Health and Social Development of Russia of 26.04.2006 N 316)

Standard diets	Numbered system diets (diets N N 1-15)	Indications for use	General Characteristics, Cooking	Proteins, incl. animals, g	Total fats, incl. vegetable, g	General carbohydrates, incl. mono- and disaccharides, g	Energy heti-ches-kaya value, kcal
1	2	3	4	5	6	7	8
	1, 2, 3, 5, 6, 7, 9, 10, 13,14, 15	Chronic gastritis in remission. Peptic ulcer and 12 duodenal ulcer in remission. Chronic bowel disease with a predominance of irritable bowel syndrome with predominantly constipation. Acute cholecystitis and acute hepatitis in the convalescent stage. Chronic hepatitis with mild signs of functional liver failure. Chronic cholecystitis and gallstone disease. Gout, uric acid diathesis, nephrolithiasis, hyperuricemia, phosphaturia. Type 2 diabetes mellitus without concomitant overweight or obesity. Diseases of the cardiovascular system with mild circulatory disorders, hypertension, coronary artery disease, atherosclerosis of the coronary arteries of the heart, cerebral, peripheral vessels. Acute infectious diseases. Feverish states.	A diet with a physiological content of proteins, fats and carbohydrates, enriched with vitamins, minerals, plant fiber (vegetables, fruits). When prescribing a diet for patients with diabetes mellitus, refined carbohydrates (sugar) are excluded. Nitrous extractives, table salt (6-8 g / day), foods rich in essential oils are limited, spicy seasonings, spinach, sorrel, smoked meats are excluded. Dishes are cooked boiled or steamed, baked. Temperature of hot dishes - no more than 60-65 ° С, cold dishes - not lower than 15 ° С. Free liquid - 1.5-2 liters. The food rhythm is fractional, 4-6 times a day.	85-90 40-45	70-80 25-30	300-330 30-40 (refined carbohydrates are excluded from the diet of patients with diabetes mellitus)	2170- 2400
	1b, 4b, 4c, 5p (option I)	Peptic ulcer and 12 duodenal ulcer in the stage of exacerbation and unstable remission. Acute gastritis. Chronic gastritis with preserved and high acidity in the stage of mild exacerbation. Gastroesophageal reflux disease. Dysfunction of the chewing apparatus. Acute pancreatitis, stage of decaying exacerbation Severe exacerbation of chronic pancreatitis. During the recovery period after acute infections; after operations (not on internal organs).	A diet with a physiological content of proteins, fats and carbohydrates, enriched with vitamins, minerals, with a moderate restriction of chemical and mechanical irritants of the mucous membrane and the receptor apparatus of the gastrointestinal tract. Spicy snacks, seasonings, spices are excluded; table salt is limited (6-8 g / day). Dishes are cooked boiled or steamed, mashed and not grated. Food temperature - from 15 to 60-65 ° С. Free liquid -1.5-2 liters. The food rhythm is fractional, 5-6 times a day.	85-90 40-45	70-80 25-30	300-350 50-60	2170- 2480
High Protein Diet Option (High Protein Diet)	4e, 4ag, 5p (option II), 7c, 7d, 9b, 10b, 11, R-I, R-II	After resection of the stomach in 2-4 months for peptic ulcer in the presence of dumping syndrome, cholecystitis, hepatitis. Chronic enteritis with the presence of a pronounced violation of the functional state of the digestive organs. Glutenic enteropathy, celiac disease. Chronic pancreatitis in remission. Chronic glomerulonephritis of the nephrotic type in the stage of decaying exacerbation without disturbances of the nitrogen-excreting function of the kidneys. Diabetes mellitus type 1 or 2 without concomitant obesity and impaired nitrogen-excreting renal function. Rheumatism with a low degree of activity of the process with a protracted course of the disease without impaired blood circulation; rheumatism in the stage of fading exacerbation. Pulmonary tuberculosis. Suppurative processes. Anemia of various etiologies. Burn disease.	A diet high in protein, normal amounts of fat, complex carbohydrates, and restricting digestible carbohydrates. When prescribing a diet for patients with diabetes mellitus and after resection of the stomach with dumping syndrome, refined carbohydrates (sugar) are excluded. Table salt (6-8 g / day), chemical and mechanical irritants of the stomach, biliary tract are limited. Dishes are cooked boiled, stewed, baked, mashed and not grated, steamed. Food temperature - from 15 to 60-65 ° С. Free liquid - 1.5-2 liters. The food rhythm is fractional, 4-6 times a day.	110-120 45-50	80-90 30	250-350 30-40	2080- 2690
Low protein diet option (low protein diet)	7b, 7a	Chronic glomerulonephritis with severe and moderate impairment of nitrogen-excreting renal function and severe and moderate azotemia.	A diet with protein restriction to 0.8 g or 0.6 g or 0.3 g / kg of ideal body weight (up to 60, 40 or 20 g / day), with a sharp restriction of table salt (1.5-3 g / day ) and liquid (0.8-1 l). Excluded are nitrogenous extractives, alcohol, cocoa, chocolate, coffee, salty snacks. The diet includes dishes from sago, protein-free bread, mashed potatoes, mousses from swelling starch. Dishes are cooked without salt, boiled, steamed, not grated. The food is cooked in a boiled form, steamed, not chopped. The diet is enriched with vitamins and minerals. Free liquid - 0.8-1.0 liters. The food rhythm is fractional, 4-6 times a day.	20-60 15-30	80-90 20-30	350-400 50-100	2120- 2650
Low Calorie Diet Option (Low Calorie Diet)	8, 8a, 8o, 9a, 10s	Various degrees of alimentary obesity in the absence of pronounced complications from the digestive system, blood circulation and other diseases requiring special dietary regimes. Type II diabetes mellitus with obesity. Cardiovascular disease if you are overweight.	A diet with moderate restriction of energy value (up to 1300-1600 kcal / day), mainly due to fats and carbohydrates. Simple sugars are excluded, animal fats, table salt (3-5 g / day) are limited. Vegetable fats, dietary fiber (raw vegetables, fruits, food bran) are included. Liquid is limited. Food is cooked boiled or steamed, without salt. Free liquid - 0.8-1.5 liters. The food rhythm is fractional, 4-6 times a day.	70-80 40	60-70 25	130-150 0	1340- 1550
High protein diet option (high protein diet (s) (introduced by the Order of the Ministry of Health and Social Development of Russia dated 04.26.2006 №316)	11	Respiratory tuberculosis: primary; infiltrative; caseous pneumonia; tuberculoma in decay phase; cavernous; cirrhotic; tuberculous pleurisy including empyema; bronchi; silicotuberculosis. Extrapulmonary tuberculosis: central nervous system; peripheral lymph nodes; abdominal organs; genitourinary system; genital; musculoskeletal system; eye; skin and mucous membranes. Tuberculosis in combination with other pathologies: HIV; diabetes mellitus; chronic obstructive pulmonary disease; toxic mania and acogolism; hepatitis; professional harm. Tuberculosis combined with multidrug resistance.	A diet with a high content of protein, fat, physiological amount of complex carbohydrates, restriction of easily digestible sugars, table salt (up to 6 g / day). A diet with increased energy value. When prescribing a diet for patients with diabetes mellitus, refined carbohydrates (sugar) are excluded. Dishes are cooked boiled, stewed, baked, with or without mechanical sparing. Food temperature - from 15 to 60-65 degrees C. Free liquid - 1.5-2 liters Rhythm of food - fractional, 4-6 times a day. When prescribing a diet for patients with diabetes mellitus, refined carbohydrates (sugar) are excluded.	130 – 140 (60 - 70)	110 – 120 (40)	400 – 500 (50) (refined carbohydrates are excluded from the diet of patients with diabetes mellitus and patients after resection of the stomach with dumping syndrome)	3100 - 3600

Table 1a

to the Instructions for the organization of therapeutic nutrition
in medical institutions

Natural food ratio
and specialized food
in the patient's daily diet

(introduced by the Order of the Ministry of Health and Social Development of Russia dated 10.01.2006 N 2,
as amended by Order of the Ministry of Health and Social Development of Russia dated April 26, 2006 N 316)

Diets	Proteins, incl. animals, g	Total fats, incl. vegetable, g	General carbohydrates, incl. mono-disaccharides, g	Energy value, kcal
Basic variant of the standard diet
	85-90 (40-45)	70-80 (25-30)	300-330 (30-40)	2170-2400
Natural food	69-72	62-71	288-316	1990-2190
Specialized products food (protein composite dry mixture)	16-18	8-9	12-14	180-210
Diet option with mechanical and chemical sparing
Chemical composition and the energy value of the diet	85-90 (40-45)	70-80 (25-30)	300- 350 (50-60)	2170-2480
Natural food	69-72	62-71	288-336	1990-2270
	16-18	8-9	12-14	180-210
High protein diet option
The chemical composition and energy value of the diet	110-120 (45- 50)	80-90 (30)	250-350 (30-40)	2080-2690
Natural food	88-96	69-78	232-330	1825-2410
Specialized food products (dry protein composite mixture)	22-24	11-12	18-20	255-280
Low protein diet option
The chemical composition and energy value of the diet	20-60 (15-30)	80-90 (20-30)	350-400 (50-100)	2120-2650
Natural food	2-38	71-79	336- 380	1910-2395
Specialized food products (dry protein composite mixture)	18-22	9-11	14-20	210-255
Reduced calorie diet option
The chemical composition and energy value of the diet	70-80 (40)	60-70 (25)	130-150 (0)	1340-1550
Natural food	54-64	52-62	118-138	1116-1420
Specialized food products (dry protein composite mixture)	16	8	12	180
Diet option with an increased amount of protein (t) (introduced by the Order of the Ministry of Health and Social Development of Russia dated 04.26.2006 N 316)
The chemical composition and energy value of the diet (introduced by the Order of the Ministry of Health and Social Development of Russia dated 04.26.2006 N 316)	130-140 (60-70)	110-120 (40)	400-500 (50)	3100-3600
Natural food products (introduced by Order of the Ministry of Health and Social Development of Russia dated April 26, 2006 N 316)	91-98	77-84	280-350	2170-2450
Specialized food products (dry composite protein mixture) (introduced by the Order of the Ministry of Health and Social Development of Russia dated April 26, 2006 N 316)	39-42	33-36	120-150	930-1150

table 2

to the Instructions for the organization of therapeutic nutrition
in medical institutions

in medical institutions

Abolished. - Order of the Ministry of Health of Russia dated 06.21.2013 N 395n.

Table 2a

to the Instructions for the organization of therapeutic nutrition
in medical institutions

Average daily set of products for one patient
in anti-tuberculosis treatment-and-prophylactic institutions

(introduced by the Order of the Ministry of Health and Social Development of Russia of 26.04.2006 N 316)

Product name
Product name	gross	net
1	2	3
Rye bread (bran)	150	150
Wheat bread	200	200
Wheat flour	50	50
Potato starch	5	5
Pasta, noodles	25	25
	75	75
Potato:
from September 1 to October 31	400	300
from November 1 to December 31	428	300
from January 1 to February 28-29	461	300
from March 1	500	300
Other vegetables	505	500
of them:
White cabbage	275	220
carrot
before January 1	120	100
from January 1	125	100
beet
before January 1	94	75
from January 1	100	75
onion	24	20
green onion	18,8	15
parsley dill	20	15
cucumbers, tomatoes, fresh greenhouse	30,6	30
	38	25
Fresh fruits	250	250
Dried fruits (compote, raisins, prunes, dried apricots)	26	20
Dried rosehip	15,0	15,0
Fruit and vegetable juices	200	200
Beef (tenderloin)	176,5	150
Chickens I category	28,6	20
Cooked sausage (diabetic, dietary, (doctoral), ham, sausages, sausages	15,6	15
Fresh fish, fresh frozen (fillet)	93,8	90
Seafood: seaweed, fish caviar	15,2	15
Cottage cheese	81,5	80
Sour cream, cream	25	25
Cheese	16	15
Chicken egg	1 PC.	1 PC.
Kefir, yogurt, fermented baked milk, yogurt, acidophilus, kumis **	207	200
Milk	300	300
Butter	40	40
Vegetable oil	25	25
Sugar*	50	50
Jam, jam, bee honey, waffles, cookies, confectionery	10	10
Tea	2	2
Coffee, cocoa	1	1
Gelatin	0,5	0,5
Pressed yeast	1	1
Salt	6,0	6,0
Tomato paste, tomato puree	5	5

** Kumis, as a rule, is used in regions where kumis is traditionally used in food and its production is developed.

Notes:

1. The average daily set of products must be supplemented with specialized food products (dry composite protein mixture) in accordance with tables 1a, 7 to the Instructions for the organization of medical nutrition in medical institutions.

2. The average daily set of products may differ from the set of products provided in this table, depending on the season (winter, spring, summer, autumn).

Table 3

to the Instructions for the organization of therapeutic nutrition
in medical institutions

Average daily set of products
for adults undergoing spa treatment

(as amended by the Order of the Ministry of Health and Social Development of Russia dated 07.10.2005 N 624)

Product name	Number of products in grams
	gross	net
1	2	3
Rye bread (bran)	150	150
Wheat bread	200	200
Wheat flour	50	50
Potato starch	10	10
Pasta, noodles	20	20
Groats (buckwheat, oatmeal, semolina, millet, pearl barley, wheat, rice), legumes (peas, beans, lentils, etc.)	95	95
Potato: from September 1 to October 31 from November 1 to December 31 from January 1 to February 28-29 from March 1	275 294 317 343	206 206 206 206
Other vegetables: of them: White cabbage	175	140
carrot: before January 1 from January 1	115 122	92 92
beet: before January 1 from January 1	55 59	44 44
onion	20	16,8
green onions, herbs and parsley root, celery	20	16
parsley, dill, celery	16	12
cucumbers, tomatoes (pumpkin, zucchini, radish, green salad, etc.)	150	147
sauerkraut, pickled cucumbers, pickled tomatoes, canned snack vegetables, pickled mushrooms	30	21
canned green peas, canned corn	30	19,5
Fresh fruits, berries	250	250
Dried fruits (compote, raisins, prunes, dried apricots), nuts	26	20
Dried rosehip	20	20
Fruit, vegetable juices, canned compotes	250	250
Beef (tenderloin), offal (liver, kidney, tongue)	150	127,5
Chickens (turkey)	57	40
Cooked sausage (diabetic, dietary, doctor's), ham, sausages, sausages	10	7,5
Fresh fish, fresh frozen	140	70
Herring Red fish, stellate sturgeon (sturgeon) Granular caviar	15 7,8 6,2	7,5 5 6
Seafood: seaweed, fish caviar squid, shrimps, trepangs, mussels, crabs	15,2 33	15 30
Cottage cheese	81,5	80
Sour cream, cream	30	30
Cheese, feta cheese	10	9,2
Chicken egg	1 PC.	1 PC.
Kefir, yogurt, fermented baked milk, yogurt, acidophilus	103,5	100
Milk	317	300
Butter	50	50
Vegetable oil	30	30
Mayonnaise	5	5
Sugar*	50	50
Jam, jam, bee honey, waffles, cookies, marshmallow, marshmallow, candy	20	20
Tea	2	2
Coffee, cocoa	1	1
Drinking water	200	200
Gelatin	1	1
Pressed yeast	2	2
Salt	10	10
Tomato paste, tomato puree	5	5
Spices, soda, citric acid	0,5	0,5

______________________________

* Refined carbohydrates (sugar and confectionery with sucrose) are excluded from the diet of patients with diabetes mellitus. Their equivalent substitution is made for specialized dietary products that do not contain sucrose.

Notes:

1. The average daily set of foods may differ from the set of foods provided in this table, depending on the season (winter, spring, summer, autumn).

2. The average daily set of products is supplemented with specialized products for dietary (therapeutic and prophylactic) nutrition.

Table 4

to the Instructions for the organization of therapeutic nutrition
in medical institutions

Products (g, ml gross)
Products (g, ml gross)	1-3 of the year	4-6 years	7-10 years	11-17 years
1	2	3	4	5
Wheat bread	60	100	150	200
Rye bread	40	50	100	150
Wheat flour	20	50	50	55
Potato flour	1	1	2	2
Cereals, legumes, pasta	35	50	65	80
Potato	150	250	300	350
Different vegetables and greens	200	300	350	400
Fresh fruits	100	200	200	250
Dry fruits	10	15	20	20
Fruit juice	150	200	200	200
Sugar	50	60	70	75
Confectionery	10	15	20	25
Butter	30	35	40	50
Vegetable oil	5	10	15	20
Egg, pcs.	1/2	1	1	1
Curd 9%	40	50	55	60
Milk, kefir and other dairy products	550	550	550	550
Sour cream	10	12	15	15
Cheese	5	10	10	10
Meat 1 cat. (including offal)	100	130	150	180
Sausages	-	15	20	25
Bird 1 cat. p / p	15	25	35	45
Seafood	-	15	15	20
Fish (fillet)	30	40	50	60
Herring, caviar	-	6	6	10
Cereal coffee, cocoa powder	2	2	3	4
Tea	0,5	0,5	1	1
Yeast	0,5	1	1	2
Salt, spices	4	5	8	10

Table 5

to the Instructions for the organization of therapeutic nutrition
in medical institutions

Average daily food sets for children,
victims of radiation exposure,
being treated in sanatoriums
institutions of various profiles (except for tuberculosis)

Products (g, ml gross)	Number per day per child aged
Products (g, ml gross)	4-6 years	7-10 years	11-17 years
1	2	3	4
Wheat bread	100	100	150
Rye bread	50	150	200
Wheat flour	35	35	40
Potato flour	2	5	5
Cereals, pasta, legumes	50	60	65
Potato	250	300	350
Different vegetables and greens	320	445	490
Fresh fruits	250	300	300
Dry fruits	15	20	20
Fruit juice	200	200	200
Sugar	60	60	60
Confectionery	15	20	25
Butter	30	40	40
Vegetable oil	10	15	20
Egg, pcs.	1	1	1
Cottage cheese	55	55	60
Milk, kefir	550	550	550
Sour cream	10	12	15
Cheese	10	10	15
Meat, incl. by-products and sausages	125	140	175
Bird	35	40	50
Fish (fillet)	50	60	70
Seafood	30	40	40
Caviar, herring	6	6	10
Coffee drink	2	3	4
Tea	0,5	1	1
Cocoa	0,5	1	1,5
Yeast	0,5	0,5	1
Salt, spices	6	8	10
Bran	-	10	15
Walnuts	5	5	5
Dried rose hips	5	5	5
Dry fortified drinks	15	20	30

Table 6

to the Instructions for the organization of therapeutic nutrition
in medical institutions

Interchangeability of products in the preparation of dietary meals

(as amended by the Order of the Ministry of Health and Social Development of Russia of 26.04.2006 N 316)

Replaceable product names	Product weight, gross, kg	Name of replacement products	Equivalent tape product weight, gross, kg	Culinary use
1	2	3	4	5
Eggs without shell	1,00	Egg melange ice cream	1,00	In egg dishes, casseroles, flour products
Also	1,00	Dry egg omelet mixture	0,35	Also
Also	1,00	Egg powder	0,28	Also
Unsalted cow butter, "Vologda"	1,00	Peasant oil	1,13	In culinary products and dishes (except for dressing dishes during holidays)
Also	1,00	Amateur cow oil	1,06	Also
Also	1,00	Salted cow oil (with a decrease in the amount of salt in the recipe by 0.02 kg) * (2)	1,00	In minced meat, pancakes, pancakes
Also	1,00	Ghee cow butter	0,84	In minced meat, pancakes, pancakes and for dressing culinary products
Sunflower oil	1,00	Peanut, corn, soybean, cottonseed, olive oil	1,00	In cold dishes, flour products, marinades, fish dishes, etc.
Refined sunflower oil	1,00	Unrefined sunflower oil	1,00	In marinades, some sauces, cold, vegetable, fish dishes, flour products
	1,00	Non-fat pasteurized cow's milk (with an increase in the bookmark in the formulation of unsalted cow butter by 0.04 kg)	1,00
Whole pasteurized cow's milk	1,00	Whole dry cow milk	0,12	In soups, sauces, egg dishes, flour products, vegetables, sweet dishes, drinks, etc.
Whole pasteurized cow's milk	1,00	Skimmed dry cow milk (with an increase in the bookmark in the formulation of unsalted cow butter by 0.04 kg)	0,09	In soups, sauces, egg dishes, sweet dishes, flour products, cereals
Also	1,00	Dry cream (with a reduction in the amount of unsalted cow butter in the recipe by 0.042 kg)	0,16	In milk porridge
Also	1,00	Whole condensed milk with sugar (with a decrease in the amount of sugar in the recipe by 0.17 kg)	0,38	In sweet foods, drinks
Also	1,00	Condensed milk sterilized in cans	0,46	In soups, sauces, sweet dishes, flour products and drinks
Also	1,00	Condensed cream with sugar (with a decrease in the bookmark in the recipe for unsalted cow butter by 0.07 kg and sugar by 0.18 kg)	0,48	In milk porridges, flour products
Granulated sugar * (3)	1,00	Natural honey	1,25	In drinks, jelly, mousse, jelly
Also	1,00	Refined powder	1,00	In sweet dishes, casseroles, puddings
Jam, jam	1,00	Fruit jelly (carved)	0,84	In sweet dishes
Also	1,00	Seedless Jam	1,00	Also
Dry potato starch (20% moisture)	1,00	Potato starch (raw 50% moisture content)	1,60	In jelly, sweet soups
Potato starch	1,00	Corn starch	1,50	In milk jelly, jelly
Pressed bakery yeast	1,00	Dry bakery yeast	0,25	For the preparation of drinks, flour products
Non-packaged black tea	1,00	Tiled black tea	1,00	For preparing drinks
Natural coffee, roasted	1,00	Natural instant coffee	0,35	Also
Vanillin	1,00	Vanilla sugar	20,0	In sweet dishes
Also	1,00	Vanilla essence	12,7	Also
Gelatin	1,00	Agaroid	0,70	In sweet, gelatinous dishes
Green peas (canned)	1,00	Vegetable peas (shoulder blade) fresh	0,82	In cold dishes, soups, vegetable dishes, side dishes
Also	1,00	Vegetable beans (shoulder), fresh	0,82	Also
Also	1,00	Fresh frozen green peas	0,71	Also
Dill, parsley, fresh celery	1,00	Dill, parsley, celery, salted sprigs (with a decrease in the amount of salt in the recipe by 0.29 kg)	1,00	For flavoring broths, soups, sauces
Also	1,00	Dill, parsley, celery, chopped salted (with a decrease in the amount of salt in the recipe by 0.22 kg)	0,76	Also
Also	1,00	Dill, parsley, celery, twigs, quick-frozen	0,76	Also
Parsnips, parsley, celery, fresh root	1,00	White parsley, celery and parsnip roots, dried	0,15	In soups, sauces, when stewing meat, fish, vegetables
Fresh sorrel	1,00	Sorrel puree (canned)	0,40	In sorrel soups
Fresh spinach	1,00	Spinach puree (canned)	0,40	In soups using spinach, in vegetable dishes
Tomatoes (tomatoes) fresh	1,00		0,46	In soups, sauces and stewing vegetables
Also	1,00		0,37	Also
Also	1,00	Natural tomato juice * (4)	1,22	Also
Tomatoes (tomatoes) fresh	1,00	Canned food. Natural whole tomatoes (rounded fruits)	1,70	In cold dishes and side dishes
Also	1,00	Canned food. Natural whole tomatoes (plum fruits)	1,42	Also
Fresh leeks	1,00	Fresh green onions	0,95	In soups, cold dishes, side dishes, vegetable dishes
Tomato puree with a dry matter content of 12%	1,00	Natural tomato juice	2,66	In soups, sauces and when stewing meat, fish, vegetables, etc.
Also	1,00	Tomato puree with a solids content of 15%	0,80	Also
Also	1,00	Tomato paste with a dry matter content of 25-30%	0,40	Also
Tomato puree with a dry matter content of 12%	1,00	Tomato paste with a dry matter content of 35-40%	0,30	Also
Also	1,00	Salted tomato paste with a dry matter content of 37% (with a decrease in the amount of salt in the recipe by 0.03 kg)	0,30	Also
Fresh apples	1,00	Apples, whole, in halves, in quarters (blanched in sugar syrup), quick-frozen	0,8/0,73*(5)	In sweet dishes
Fresh lingonberry	1,00	Fresh cranberries	1,00	In cabbage salads and sweet dishes
Dried apricots	1,00	Dried apricots, kaisa	0,75	In puddings, sweet sauces, dishes
Dried grapes (raisins, sabza)	1,00	Candied fruits, kaisa, dried apricots	1,00	Also
Kernel of a nut, sweet almonds	1,00	Kernels of walnuts, hazelnuts, peanuts	1,00	In sweet dishes, puddings
Citric acid food	1,00	Tartaric acid food	1,00	In dishes where citric acid is used
Also	1,00	Lemon juice	8,00	Also

Notes:

* (1) When using butter for dressing when dispensing dishes, the amount of replacement and replacement oil of other types is the same.

* (3) Despite the fact that sorbitol is half as sweet as sucrose, its interchangeability rate is 1: 1.

* (4) Calculation of the rate of substitutions was made in accordance with GOST.

* (5) Numerator - mass of apples when defrosting a semi-finished product in air, denominator - mass of apples when defrosting a semi-finished product in sugar syrup.

Table 7

to the Instructions for the organization of therapeutic nutrition
in medical institutions

Substitution of products for proteins and carbohydrates

(as amended by the Order of the Ministry of Health and Social Development of Russia of 26.04.2006 N 316)

Product name	Number of products in net, g	Chemical composition			Add to the daily ration (+) or exclude from it (-)
Product name	Number of products in net, g	proteins, g	fat, g	carbohydrates, g	Add to the daily ration (+) or exclude from it (-)
1	2	3	4	5	6
Replacement of bread (for protein and carbohydrates)
Wheat bread from flour I p.	100	7,5	2,9	51,4
Simple molded rye bread	125	7,62	1,5	49,87
Wheat flour I p.	70	7,42	0,91	48,3
Pasta, noodles I c.	70	7,7	0,91	49,35
Semolina	75	7,72	0,9	52,95
Potato replacement (carbohydrate)
Potato	100	2,0	0,4	16,3
Beet	190	2,85	0,19	16,72
Carrot	240	3,12	0,24	16,56
Cabbage w / c	370	6,66	0,37	17,39
Pasta, noodles I c.	25	2,75	0,32	17,62
Semolina	25	2,57	0,25	17,65
Wheat bread from flour I p.	35	2,62	1,01	17,99
Simple molded rye bread	45	2,74	0,54	17,95
Replacement of fresh apples (by carbohydrates)
Fresh apples	100	0,4	0,4	9,8
Dried apples	15	0,33	0,01	8,85
Dried apricots (seedless)	18	0,94	0,05	9,18
Prunes	15	0,34	0,1	8,63
Protein milk replacement
Milk	100	2,9	3,2	4,7
Bold cottage cheese	16	2,88	1,44	0,48
Fat cottage cheese	20	3,0	3,6	0,56
Cheese	13	3,02	3,83	-
Beef I grade	15	2,79	2,4	-
Beef II grade	15	3,0	1,47	-
Beef tenderloin	15	3,03	0,42	-
Cod fish)	20	3,2	0,12	-
Specialized food products (dry protein composite mixture)	7	2,8	1,4	2,1
Meat replacement (protein)
Beef I grade	100	18,6	16,0	-
Beef II grade	90	18,0	8,82	-	oil + 7 g
Beef tenderloin	90	18,18	2,52	-	oil + 13 g
Bold cottage cheese	100	18,0	9,0	3,0	oil + 5 g
Fat cottage cheese	120	18,0	21,6	3,7	oil - 5 g
Cod fish)	115	18,4	0,69	-	oil + 5 g
Chicken egg	145	18,4	16,67	1,01
Specialized food products (dry protein composite mixture)	45	18,0	9,0	13,68
Substitution of fish (by protein)
Cod fish)	100	16,0	0,6	-
Beef I grade	85	15,81	13,6	-	oil - 13 g
Beef II grade	80	16,0	7,84	-	oil - 7 g
Beef tenderloin	80	16,6	2,24	-
Bold cottage cheese	90	16,2	8,1	2,7	oil - 7 g
Fat cottage cheese	110	16,5	19,8	3,08	oil - 19 g
Chicken egg	125	15,87	14,37	0,87	oil - 13 g
Specialized food products (dry protein composite mixture)	40	16,0	8,0	12,2
Replacement of cottage cheese (protein)
Bold cottage cheese	100	18,0	9,0	3,0
Beef I grade	100	18,6	16,0	-	oil - 7 g
Beef II grade	90	18,0	8,82	-
Beef tenderloin	90	18,18	2,52	-	oil + 6 g
Cod fish)	110	17,6	0,66	-	oil + 8 g
Chicken egg	140	17,78	16,1	0,98	oil - 7 g
Specialized food products (dry protein composite mixture)	45	18,0	9,0	13,68
Egg replacement (by protein)
Chicken egg	40	5,08	4,6	0,28
Bold cottage cheese	30	5,4	2,7	1,2
Fat cottage cheese	35	5,25	6,3	0,98
Cheese	22	5,1	6,49	-
Beef I grade	30	5,58	4,8	-
Beef II grade	25	5,0	2,45	-
Beef tenderloin	25	5,05	0,7	-
Cod fish)	35	5,6	0,73	-
Specialized food products (dry protein composite mixture)	12,7	5,08	2,5	3,8

Meal Discharge Procedure

for patients in medical institutions

1. Discharge of food is carried out by a dietary nurse under the guidance of a dietitian.

In medical institutions where the position of a nutritionist is absent, nutritional discharge is performed by a nutritionist nurse under the supervision of a doctor responsible for medical nutrition.

2. When a patient enters a medical and prophylactic institution, medical nutrition is appointed by the doctor on duty. The prescribed diet is entered in the medical history and simultaneously in the consolidated order for all admitted patients, which is sent to the catering unit at the set time.

3. Diet records are kept by ward nurses, who daily report to the head nurse of the department the number of patients and their distribution according to diets. On the basis of this information, the senior nurse of the department draws up on form N 1-84 "Portions for the nutrition of patients", which is signed by her, the head of the department and transferred to the nutritional unit by a dietetic nurse.

4. The nurse of the dietary catering unit, based on the information received from all departments, draws up "Summary information on the presence of patients who are on meals" in the medical and prophylactic institution, which are verified with the data of the admission department and signed by it (form N 22-MZ).

5. On the basis of the "Summary information" dietary nurse with the participation of the head. production (the chef) and the accountant, under the guidance of a nutritionist, draws up a menu-layout according to the form N 44-MZ for the nutrition of patients the next day.

The layout menu is compiled according to the summary seven-day menu taking into account the average daily set of food products, it is approved daily by the head physician of the institution and signed by a dietitian, accountant, head. production (by the chef). In the layout menu, the dietary nurse in the numerator puts down the number of food products for preparing one portion of each dish, in the denominator the accountant (calculator) indicates the number of products required to prepare all portions of this dish.

6. On the basis of the final data of the form N 44-MZ, the "Requirement for the issue of food products from the warehouse (pantry)" is written out in form N 45-MZ in two copies.

7. The foodstuffs are loaded into the cauldron in the presence of a dietitian (dietetic nurse). Food products are pre-weighed regardless of the fact that they were received by weight from the warehouse (pantry).

8. Issuance of food rations to the departments is made according to the form N 23-MZ ("Statement for the release of food rations for patients"), which is filled in by the dietary nurse in one copy. When giving out breakfasts, lunches and dinners, the employees of the departments sign for their receipt. The statement is signed by the dietetic nurse and the head. production (by the chef).

Buffet products (butter, bread, tea, salt, etc.) are handed out to barmaids directly from the warehouse (pantry) at the request of Form N 45-MZ.

9. An additional statement and / or return of products is made according to the invoice (demand) to the warehouse (storeroom) in the form N 434. Food products placed in the boiler cannot be returned.

10. Supplementary food prescribed in the department to dietary rations is drawn up in duplicate, signed by the attending physician, the head of the department and approved by the chief physician of the medical and preventive institution. The first is transferred to the catering unit, the other is kept in the history of the disease.

11. For each dish prepared in a medical institution, a layout card is drawn up in two copies according to Form N 1-85: one copy is kept by the accountant, the second - by the dietary nurse (the back of the card describes the cooking technology).

The order of control over the quality of finished food in a medical institution

1. Control of the finished food before its delivery to the departments is carried out by the doctor on duty and once a month - by the chief doctor (or his deputy for medical work) of the medical and preventive institution, and is also carried out by a dietitian, dietary nurse, head. production (or a chef), regardless of the sample produced by the doctor on duty.

2. Checking the finished food at the catering unit before its delivery to the departments is carried out in the following order:

a) directly from the boiler, in accordance with the list of dishes indicated in the layout menu.
The volume of the first courses is set based on the capacity of the pot or kettle and the number of ordered portions and the volume of one portion. The weight of the second courses (porridge, puddings, etc.) is determined by weighing the total amount in the common dish minus the tare weight and taking into account the number of servings. Portion dishes (cutlets, meatballs, meat, poultry, etc.) are weighed in the amount of 10 portions and the average weight of one portion is set. Weight deviations from the norm should not exceed 3%;

b) by taking a sample of the prepared dish of one of the diets used.

3. The results of the food sample are recorded by the doctor on duty in the prepared food log (Form No. 6-lp).

4. The selection of ready-made dishes for laboratory analysis (determination of the chemical composition and energy value, taking into account losses during cold and heat treatment) is carried out by the institutions of the State Sanitary and Epidemiological Supervision of the Ministry of Health of the Russian Federation in a planned manner in the presence of a nutritionist or nutritionist nurse.

Technological equipment the catering unit is divided into mechanical, thermal and refrigeration.

1. Mechanical equipment is used for the primary processing of products, it includes:

a) machines for processing cereals, potatoes and vegetables (grinder, potato peelers, vegetable cutters, shredders, pullers, juicers);

b) machines for processing meat and fish (meat grinders, meat mixers, special devices for cleaning fish from scales, cutlet machine, saws for cutting meat carcasses);

c) machines for dough preparation (sifters, dough mixers, a mechanism for laying out and dividing dough);

d) dishwashing machines (or baths for hand wash tableware and bathtubs for washing kitchen utensils);

e) machines for cutting bread, egg slicers;

f) whipping machine for liquid mixtures.

2. Heating equipment is used for thermal processing of products (cooking, frying, baking, steaming, combined processing).

a) cooking equipment includes boilers, sauce boilers, steamers, apparatus for boiling eggs, sausages;

b) frying equipment includes electric pans, electric crucibles, electric stoves, microwave ovens. Frying ovens (with T - 150 - 200 degrees); drying cabinets (T - 100 - 150 degrees), baking cabinets (T - up to 300 degrees).

3. Non-mechanized equipment:

a) cutting tables, cutting boards, shelves, carts, scales, cabinets for storing kitchen utensils and appliances, chests, cutting decks;

b) pots, buckets, baking sheets, frying pans, sieves, veils, teapots;

c) inventory: knives, forks, shovels, mortars, molds, strainers, slotted spoon, etc.

4. Refrigeration equipment represented by refrigerators and refrigerated cabinets.

5. The premises of the canteens at the departments of medical and prophylactic institutions should be provided with:

a) cold and hot running water, regardless of the presence of a hot water supply network; pantries should be equipped with continuous electric boilers;

b) two-section washing baths that are connected to the sewage system; a tank for soaking (disinfection) or boiling dishes;

c) detergents and disinfectants;

d) nets for drying dishes, appliances and for storing food (bread, salt, sugar);

f) a cabinet for storing household equipment;

g) food warmer or electric stove for heating food;

h) a table with a hygienic cover for serving food;

i) a table for dirty dishes;

j) a set of dishes per patient: one deep, shallow and dessert plate, fork, spoons (table and tea); mug, and in children's departments with a margin, according to the equipment sheet;

k) cleaning equipment (buckets, rags, brushes, etc.) marked "for the pantry".

Responsibility for the right equipment the catering unit and pantry departments of the medical and prophylactic institution are carried by the deputy chief physician for administrative and economic matters and a nutritionist.

Transportation of prepared food

a) in the absence of a centralized circular delivery of food products, special transport (covered) is allocated for their transportation, which is subject to certification at least once a year in the institutions of the State Sanitary and Epidemiological Supervision. It is strictly forbidden to use this transport for other purposes (transportation of linen, equipment, patients, etc.).

b) thermoses, thermos trolleys, bain-marie trolleys or tightly closing dishes are used to transport ready-made food to the canteen departments of the hospital.

Sanitary and hygienic regime of the catering unit and pantries

1. In the food blocks of medical and preventive institutions, the following must be strictly observed:

Requirements for the arrangement of the catering unit, sanitary maintenance and cooking technology provided for by the current sanitary rules for enterprises Catering;

Sanitary rules for the conditions and periods of storage and sale of highly perishable products;

Requirements for compulsory preventive and medical examinations of workers in the catering unit, distribution and pantry (forms 1-lp and 2-lp).

It is strictly forbidden in the premises of the catering unit to wash tableware from the departments of the medical and prophylactic institution. Dishes are washed only in the washing cabinets of the compartments in compliance with the dishes disinfection regime.

Distribution of ready-made food is carried out no later than 2 hours after its preparation, including the time of delivery of food to the department.

The food is distributed to the sick by the barmaids and the duty nurses of the department. Food distribution should be carried out only in a dressing gown marked "For food distribution".

The technical staff, who are busy cleaning the wards and other premises of the department, are not allowed to the distribution. Meals for all patients of the department, with the exception of seriously ill patients, are carried out in a specially designated room - a dining room. Personal food products of patients (transfers from home) are stored in a closet, a bedside table (dry food) and in a special refrigerator (perishable food).

Transfers to patients are accepted only within the range and quantity of products permitted by the doctor.

After each distribution of food, the pantry and canteen rooms are thoroughly cleaned using solutions of disinfectants.

After washing, the cleaning material is poured with a 0.5% clarified solution of bleach or 1% chloramine solution for 60 minutes, then rinsed in running water and dried (the inventory is used strictly as intended).

The staff of the catering and pantry are obliged to observe the rules of personal hygiene. Before visiting the toilet, staff must take off the dressing gown, after visiting, they must brush their hands with a brush using disinfectants or laundry soap.

Responsible for compliance with sanitary requirements in the preparation and delivery of ready-made food in the catering unit is the head. production (chef), dietary nurse, dietitian, and in the department - barmaids and senior nurses.

By letter of the Ministry of Health of Russia dated April 7, 2004 N 2510 / 2877-04-32, it was reported that the duration of storage of daily samples of ready-made food is 48 hours instead of those indicated in the following paragraph "during the day".

Daily samples of prepared food are left daily in the amount of one portion or 100 - 150 g of each dish, placed in a clean boiled one for 15 minutes. labeled dishes with a lid, which are stored in a separate refrigerator for 24 hours.

List of catering unit documentation for the discharge of meals and control over the quality of finished food in medical institutions

Form N 1-84

to the Instructions for the organization of therapeutic nutrition
in medical institutions

Portion maker

for the nutrition of patients "__" __________ 20__

Head Branch (signature)

Art. honey. branch sister (signature)

Honey. sister of the dietary department (signature)

Form N 22-MZ

to the Instructions for the organization of therapeutic nutrition
in medical institutions

Institution name __________________________________________________

Summary information on the presence of patients on meals

at ___ hours "__" ________ 20__

(Back side)

Individual and additional meals
(as well as nutrition for mothers who are in a medical facility with babies)

Form N 23-MZ

to the Instructions for the organization of therapeutic nutrition
in medical institutions

Handout sheet

On vacation to food ration departments

(meals: breakfast, lunch, dinner, etc.)

20__ g.

Diet nurse ______ Head of production (chef) _____

Form N 1-85

to the Instructions for the organization of therapeutic nutrition
in medical institutions

Name medical institution ________________________________________

Approved by: ____________

Head of the institution

Layout card N

Name of the dish _______________________________________________________

Indication for use ___________________________________________________

Product name	Gross	Net	Chemical composition				Price
Product name	Gross	Net	Proteins, g	Fat, g	Carbohydrates, g	Calorie content, kcal	Price






Ready meal weight:

Nutritionist (dietary nurse)

Head of production (chef)

Accountant

Card turnover

Cooking technology: ________________________________________________

Form N 44-MZ

to the Instructions for the organization of therapeutic nutrition
in medical institutions

"I approve"

Chief physician (signature)

Institution name _________________________________________________

Layout menu for cooking meals on ________________________

patients on "__" ___________ 20__

Day of week

Name

Ko-li-chesh-your dishes

N dishes on kart-tek

Name of products, in grams

Output of ready-made dishes

M
I am
with
O

I AM
th
c
a

T
v
O
R
O
G

M
O
l
O
To
O

WITH
a
NS
a
R

Fruit juice

Sour cream

Butter

Vegetable oil

TO
a
R
T
O
f
e
l
b

TO
a
NS
at
with
T
a

M
at
To
a

NS
l
e
b

Green pea

I AM
b
l
O
To
and

Shiver pres-so-van-ny

L
and
m
O
n

Standard diets

Reception of food and dishes included in it

B
at
f
e
T

TO
at
NS
n
I am

B
at
f
e
T

TO
at
NS
n
I am

B
at
f
e
T

TO
at
NS
n
I am

Total:

Nutritionist (signature)

Diet nurse (signature)

Head of production (chef) (signature)

Accountant (signature)

Form 1-lp

to the Instructions for the organization of therapeutic nutrition
in medical institutions

I. Information about the owner of the medical record.

II. Mark of transfer to work in other institutions.

III. Medical examination results.

IV. Results of the study for tuberculosis.

V. Results of research on bacilli carrier.

Vi. Test results for worms.

Vii. Notes on the transferred infectious and intestinal diseases.

VIII. Passing the exam for the sanitary-technical minimum.

IX. Preventive vaccination mark.

X. Special marks of sanitary inspection about this employee (violation of the rules

personal hygiene, sanitary inspection requirements, etc.).

Form 2-lp

to the Instructions for the organization of therapeutic nutrition
in medical institutions

Health magazine

Form 3-lp

to the Instructions for the organization of therapeutic nutrition
in medical institutions

Journal of C-vitaminization of dishes

Form 6-lp

to the Instructions for the organization of therapeutic nutrition
in medical institutions

Food quality control log (rejection)

* - when replacing individual dishes for breakfast, lunch or dinner, make a corresponding entry

Appendix 5

Approved by the Order of the Ministry
health care of the Russian Federation
dated 05.08.2003 N 330

INSTRUCTIONS FOR ORGANIZING ENTER FOOD

IN MEDICAL AND PREVENTIVE INSTITUTIONS

(as amended by the Order of the Ministry of Health and Social Development of Russia of 26.04.2006 N 316)

Enteral nutrition is a type of nutritional therapy in which nutrients are introduced through a gastric (intraintestinal) tube when it is impossible to adequately provide the body's energy and plastic needs in a natural way in a number of diseases.

In medical institutions, the organization of enteral nutrition is carried out by anesthesiologists-resuscitators, gastroenterologists, therapists, surgeons, phthisiatricians, united in a nutrition support team, who have undergone special training in enteral nutrition.

(as amended by the Order of the Ministry of Health and Social Development of Russia of 26.04.2006 N 316)

The purchase of nutritional mixtures for enteral 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 of December 21, 2005 N 152n (in accordance with the letter of the Ministry of Justice of the Russian Federation of January 10, 2006 N 01 / 32-ЕЗ The order does not need state registration) under article 340 of the economic classification of budget expenditures of the Russian Federation "Increase in the cost of inventories" with the inclusion of nutritional mixtures for enteral nutrition to the section "medicines and dressings."
(as amended by the Order of the Ministry of Health and Social Development of Russia of 26.04.2006 N 316)

Members of the nutritional support team: conduct classes on enteral nutrition with doctors of a medical and preventive institution; provide advice to doctors of other specialties and analyze the clinical and economic efficiency of enteral nutrition of patients.

Indications for the use of enteral nutrition

Protein-energy deficiency when it is impossible to ensure an adequate intake of nutrients:

Neoplasms, especially those localized in the head, neck and stomach;

Disorders of the central nervous system: coma, cerebrovascular strokes or Parkinson's disease, as a result of which nutritional disorders develop;

Radiation and chemotherapy for cancer;

Diseases of the gastrointestinal tract: Crohn's disease, malabsorption syndrome, short bowel syndrome, chronic pancreatitis, ulcerative colitis, liver and biliary tract diseases;

Nutrition in the pre- and postoperative periods;

Trauma, burns, acute poisoning;

Complications of the postoperative period (fistulas of the gastrointestinal tract, sepsis, incompetence of the anastomoses sutures);

Infectious diseases;

Mental disorders: anorexia nervosa, severe depression;

Acute and chronic radiation injuries;

Widespread and generalized forms of tuberculosis with seeding and disintegration, with significant weight deficiency, tuberculosis in combination with HIV in III B and further stages; pre- and postoperative periods; local forms of tuberculosis in children early age and in adolescence.

Contraindications to the use of enteral nutrition

Intestinal obstruction;

Acute pancreatitis;

Severe malabsorption.

Eating disorders assessment

When prescribing enteral nutrition, as well as when choosing the composition of nutritional mixtures and determining the dosage, it is necessary to control the degree of violations of the nutritional status. At the first stage, with the help of anamnesis and clinical examination of patients, risk groups for malnutrition are identified. In patients at risk, a more detailed assessment of the nutritional status is carried out and, if necessary, appropriate treatment is prescribed.

The nutritional status is assessed according to indicators, the totality of which characterizes the nutritional status of the patient and his need for nutrients:

a) anthropometric data:

Height
- body mass
- body mass index (BMI)
- shoulder circumference
- Measurement of the triceps skin and fat fold (CFST)

b) biochemical indicators:

Total protein
- albumin
- transferrin

c) immunological indicators:

Total lymphocyte count

(as amended by the Order of the Ministry of Health and Social Development of Russia of 26.04.2006 N 316)

Observation map
patient receiving enteral nutrition

(insert in the medical card of an inpatient, registration form N 003 / U)

The name of the medical institution ________________________

N medical history _______________________________________________________

FULL NAME. __________________________ Gender _____ Age _____________________

Height ______________________ Body weight on admission _____________ (kg),

at discharge ______________ (kg).

Body mass dynamics for the last 6 months ______________________________

Clinical diagnosis:_____________________________________________________

_________________________________________________________________________

N	Indicators	Initial data	After treatment	Standards	Malnutrition
	Indicators	Initial data	After treatment	Standards	easy	average	heavy
	Points			3	2	1	0
1	BMI kg / m2			25-19	19-17	17-15	<15
2	Shoulder circumference, cm
	men			29-26	26-23	23-20	<20
	women			28-25	25-22,5	22,5-19,5	<19,5
3	КЖСТ, mm
	men			10,5-9,5	9,5-8,4	8,4-7,4	<7,4
	women			14,5-13	13-11,6	11,6-10,1	< 10,1
4	Shoulder muscle circumference, cm
	men			25,7-23	23-20,5	20,5-18	<18
	women			23,5-21	21-18,8	18,8-16,5	<16,5
5	Total protein, g / l			265	65-55	55-45	<45
6	Albumin, g / l			>35	35-30	30-25	<25
7	Transferrin, g / l			82,0	2,0-1,8	1,8-1,6	<1,6
8	Lymphocytes, thous.			>1,8	1,8-1,5	1,5-0,9	<0,9

	Points total			24	24-16	16-8	8

BMI - body mass index: weight / height m2

KJST - triceps skin and fat fold.

To carry out enteral nutrition, it is necessary to determine the energy requirements of the body. Determination of energy expenditure is necessary using direct or indirect calorimetry methods. If it is impossible to carry out these research methods, the assessment of energy needs can be carried out by calculation using the appropriate equations:

by the Harris-Benedict equation:

DRE = OEO x FA x FT x TF x DMT,

where ERE is the actual energy consumption (kcal / day);

OEE - basic energy exchange;

FA - activity factor; FT - trauma factor;

TF - temperature factor; DMT - underweight.

OEE (men) = 66 + (13.7 x MT) + (5 x P) - (6.8 x B)

OEE (women) = 655 + (9.6 x MT) + (1.8 x P) - (4.5 x B)

where MT is body weight (kg);

P - height (cm);

B - age (years).

For the most accurate determination of energy expenditure in severe conditions of patients, it is necessary to use the following amendments to the Harris-Benedict equation:

Energy security of the main nutrients:

1 g carbohydrates = 4 kcal

1 g protein = 4 kcal

1 g fat = 9 kcal

The need for nutrients depends on the degree of malnutrition (Table 8) and the nature of the disease (Table 9).

Choice of the composition of mixtures for enteral nutrition

When choosing a formula for enteral nutrition, you should be guided by the list below of mixtures for enteral nutrition approved for use by the Ministry of Health of Russia.
(as amended by the Order of the Ministry of Health and Social Development of Russia of 26.04.2006 N 316)

The choice of mixtures for adequate enteral nutrition should be based on the data of clinical, instrumental and laboratory examination of patients, is associated with the nature and severity of the course of the disease and the degree of preservation of the functions of the gastrointestinal tract (GIT).

With normal needs and the safety of the gastrointestinal tract functions, standard nutritional mixtures are prescribed.

For increased protein and energy requirements or fluid restriction, high-calorie nutritional formulas are prescribed.

Pregnant and breastfeeding women should be given formula for this group.

In critical and immunodeficient conditions, nutritional mixtures are prescribed with a high content of biologically active protein, enriched with trace elements, glutamine, arginine, omega-3 fatty acids.

Patients with type I and II diabetes mellitus are prescribed nutritional mixtures with a low content of fats and carbohydrates, containing dietary fiber.

If your lung function is impaired, a high-fat, low-carbohydrate nutritional formula is prescribed.

In case of impaired renal function, nutritional mixtures containing highly biologically valuable protein and amino acids are prescribed.

For liver dysfunctions, nutritional mixes are prescribed that are low in aromatic amino acids and high in branched chain amino acids.

In case of partially impaired gastrointestinal tract functions, nutritional mixtures based on oligopeptides are prescribed.
(as amended by the Order of the Ministry of Health and Social Development of Russia of 26.04.2006 N 316)

With non-functioning intestines (intestinal obstruction, severe malabsorption), the patient must be prescribed parenteral nutrition.

With active tuberculosis of the process, special high-protein mixtures are prescribed, developed for enteral nutrition of patients with tuberculosis.
(the paragraph was introduced by the Order of the Ministry of Health and Social Development of Russia of April 26, 2006 N 316)

Table 8

to the Instructions for the organization of enteral nutrition
in medical institutions

Essential Nutrient Requirements (Protein, Fat, Carbohydrate)
depending on the degree of malnutrition

(as amended by the Order of the Ministry of Health and Social Development of Russia of 26.04.2006 N 316)

Table 9

K Instructions for the organization of enteral nutrition
in medical institutions

Protein requirements for certain diseases

Methods of administering enteral nutritional mixtures

Depending on the duration of the course of enteral nutrition and the safety of the functional state of various parts of the gastrointestinal tract, the following routes of administration of nutritional mixtures are distinguished:

1. Drinking nutritional mixtures in the form of drinks through a tube in small sips;

2. Tube feeding using nasogastric, nasoduodenal, nasojejunal and two-channel probes (for aspiration of gastrointestinal contents and intraintestinal administration of nutrient mixtures, mainly for surgical patients).

3. By imposing a stoma: gastro-, duodeno-, jejuno-, ileostomy. Stomas can be placed surgically or endoscopically.

Control over the effectiveness of enteral nutrition is carried out by the attending physician together with a member of the nutritional support team by monitoring a number of indicators of the patient's condition.

Clinical data
Indicators	Day of observation
Temperature
Pulse
HELL
Breathing rate
Flatulence
Chair
Water loss, l: - diuresis - perspiration (0.8 l) - by probes
Somatometric data
Body weight, kg
BMI kg / m2
Shoulder circumference, cm
Fold thickness over triceps, mm
Shoulder muscle circumference, cm

Indicators	Measurement date

Laboratory data
- hemoglobin
- erythrocytes
- leukocytes
- lymphocytes
- hematocrit
- blood osmolarity
- total protein
- albumin
- transferrin
- urea
- creatinine
- cholesterol
- glucose
- potassium
- sodium
- calcium
- chlorides
- ALAT
- AsAT
- bilirubin
Biochemistry of urine:
- total nitrogen
- aminazot
- urea
- creatinine

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