Order 330 dated 05.08 03. Normative legal documents

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

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

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

2.1. To impose on the heads of medical and preventive institutions personal responsibility for accounting, safety, dispensing, prescribing and using narcotic drugs and psychotropic substances and special prescription forms, in accordance with Appendices 1-11 introduced by this Order. (As amended by the Order of the Ministry of Health of the Russian Federation dated May 16, 2003 N 205)

2.2. Provide medical and preventive institutions with special prescription forms for narcotic drugs and psychotropic substances obtained from pharmacy warehouses (bases). The stock of special prescription forms for narcotic drugs and psychotropic substances in the health authorities and medical and preventive institutions should not exceed the monthly requirement. (As amended by the Order of the Ministry of Health of the Russian Federation dated May 16, 2003 N 205)

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

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

2.5. To oblige attending physicians or doctors on duty to hand over used ampoules from narcotic drugs and psychotropic substances on the same day, except for weekends and public holidays, deputy head of the medical department, and in institutions where he is absent - to the head of the medical and preventive institution. The destruction of used ampoules should be carried out at least once every 10 days by a commission chaired by the head with the execution of the relevant act in the prescribed form (Appendix 10). (As amended by the Order of the Ministry of Health of the Russian Federation dated May 16, 2003 N 205)

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

4. Heads of health care management bodies and pharmaceutical organizations in the constituent entities of the Russian Federation systematically organize checks on the correctness of the appointment and registration of persons admitted (including temporarily) to work on the receipt, storage, accounting and dispensing of narcotic drugs and psychotropic substances in pharmacies and medical and preventive institutions. In case of revealing the facts of violation of the order of appointment and admission of persons to work with narcotic drugs and psychotropic substances, the perpetrators shall be brought to strict liability in accordance with the legislation of the Russian Federation. (As amended by the Order of the Ministry of Health of the Russian Federation dated May 16, 2003 N 205)

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

6. To consider as not valid on the territory of the Russian Federation Order of the Ministry of Health of the USSR dated 30.12.82 N 1311 "On measures to eliminate serious shortcomings and further strengthen the fight against drug addiction, improve accounting, storage, prescribing and use of narcotic drugs and psychotropic substances" (Appendix 2 "Form of a special prescription form for a narcotic drug and psychotropic substance", Appendix 3 "Consumption rates for narcotic drugs and psychotropic substances", Appendix 4 "Form of extraordinary report submitted to the Ministry of Health of the USSR on the theft and theft of drugs from pharmacies and medical institutions", Appendix 5 "Rules for the storage and accounting of narcotic drugs and psychotropic substances in self-supporting pharmacies", Appendix 6 "Rules for the storage and accounting of narcotic drugs and psychotropic substances and special prescription forms in medical institutions", Appendix 7 "Rules for the storage, accounting and dispensing of narcotic drugs and psychotropic substances and special prescription forms for drugs pharmaceuticals in pharmacy warehouses", Appendix 8 "Rules for the storage and accounting of narcotic drugs in control and analytical laboratories of pharmacy departments", Appendix 9 "Rules for the storage and accounting of narcotic drugs in scientific -research institutes, laboratories and educational institutions of the healthcare system", Appendix 10 "Regulations on the write-off and destruction of narcotic drugs and psychotropic substances and special prescriptions not used by cancer patients", Appendix 11 "Act on the destruction of used ampoules from narcotic drugs and psychotropic substances in healthcare institutions"). (As amended by the Order of the Ministry of Health of the Russian Federation dated May 16, 2003 N 205)

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

Minister
T.B. DMITRIEV

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

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

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

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

APPENDIX 2. FORM OF SPECIAL PRECISION FORM FOR NARCOTIC DRUG AND PSYCHOTROPIC SUBSTANCE - No longer valid. (As amended by the Order of the Ministry of Health and Social Development of the Russian Federation dated November 17, 2010 N 1008n)

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

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

Table 1

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

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

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

Note. The standards are established by recalculating all dosage forms for a purely active substance, and therefore, when comparing the application with the estimated need according to the standards, all dosage forms containing these substances should be recalculated for a purely active drug.

Chairman
Standing Committee
drug control
E.A. BABAYAN

table 2

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

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

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

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

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

Notes:

1) The heads of the health authorities of the constituent entities of the Russian Federation are allowed, on the proposals of the heads of medical and preventive institutions, to increase the calculation standards given in this table, but not more than 1.5 times. (as amended by the Order of the Ministry of Health of the Russian Federation of 09.01.2001 N 2)

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

3) If there are medical indications for the relief of severe pain in the departments of medical institutions indicated in this table, it is allowed to use non-invasive forms of narcotic drugs and psychotropic substances in quantities corresponding to medical indications and the patient's condition. (As amended by the Orders of the Ministry of Health of the Russian Federation dated 01/09/2001 N 2, dated 05/16/2003 N 205)

Chairman
Standing Committee
drug control
E.A. BABAYAN

Table 3

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

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

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

<*>In terms of pure active substance.

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

Chairman
Standing Committee
drug control
E.A. BABAYAN

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

Appendix 4
APPROVED
Order of the Ministry
health care
Russian Federation
dated November 12, 1997 N 330

APPENDIX 4. RULES OF STORAGE AND ACCOUNTING OF NARCOTIC DRUGS AND PSYCHOTROPIC SUBSTANCES IN PHARMACIES - No longer valid. (As amended by the Order of the Ministry of Health and Social Development of the Russian Federation dated November 17, 2010 N 1008n)

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

Ministry of Health of the Russian Federation

About improvement measures
therapeutic nutrition in medical and preventive
institutions of the Russian Federation

dated 07.10.2005 No. 624, dated 10.01.2006 No. 2, dated 04.26.2006 No. 316,
Order of the Ministry of Health of Russia dated June 21, 2013 No. 395n,
Prikaz of the Ministry of Health of Russia dated November 24, 2016 No. 901n)

In order to implement the Concept public policy in the field of healthy nutrition of the population of the Russian Federation for the period up to 2005, approved by the Decree of the Government of the Russian Federation of 10.08.1998 N 917, improving the organization of clinical nutrition and increasing the effectiveness of its use in the complex treatment of patients, I order:

1. Approve:

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

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

1.3. Regulations on the Council for Clinical Nutrition (Appendix N 3);

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

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

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

Minister
Yu.L. Shevchenko

A comment

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

Appendix No. 1

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

POSITION

ABOUT THE ORGANIZATION OF THE ACTIVITIES OF A NUTRITIONAL DOCTOR

1. The position of a dietician is assigned to a specialist doctor who has training in clinical nutrition and a certificate in the specialty "dietology".

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

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

4. A 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 case histories according to the prescribed diets and the stages of diet therapy;

d) analyze the effectiveness of therapeutic nutrition;

e) check the quality of products upon their receipt at the warehouse and catering department; control the correct storage of food stock;

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

g) prepare documentation on the organization of medical nutrition:

Layout cards;

Seven-day menu;

Seven-day summary menu - summer and winter version;

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

i) to control the quality of prepared 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 grocery home transfers for a patient who is being treated in a medical institution;

k) control the timeliness of preventive medical examinations of catering and pantry workers and not allow people who have not undergone preventive medical examinations, and patients with pustular, intestinal diseases, tonsillitis, to work;

l) systematically organize the improvement of the qualifications of food unit workers on the issues of clinical nutrition;

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

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

Appendix No. 2

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

POSITION

ON ORGANIZATION OF MEDICAL ACTIVITIES

SISTERS DIETARY

1. A specialist with a secondary medical education who has special training in clinical nutrition and a certificate in the specialty "dietology" is appointed to the position of a dietary nurse.

2. Nurse dietary works under the guidance of a dietitian.

3. The dietary nurse monitors the work of the catering department and the observance of sanitary and hygienic rules by the employees of the catering department.

4. The dietary nurse is obliged to:

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

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

c) monitor the correct laying of products during cooking and marriage finished products, carry out sampling of prepared food;

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

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

f) organize and personally participate in conducting classes with an average medical staff and employees of the catering department on issues of clinical nutrition;

g) maintain medical records;

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

i) level up vocational training at least once every 5 years.

Appendix No. 3

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

POSITION

ABOUT THE THERAPEUTIC NUTRITION COUNCIL

TREATMENT AND PREVENTIVE INSTITUTIONS

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

2. Number of members of the Therapeutic Nutrition Council and its personnel approved by the order of the head physician of the institution.

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

4. Tasks of the Council for Therapeutic Nutrition:

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

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

d) approval of the nomenclature of diets, mixtures for enteral nutrition, dry protein composite mixtures for therapeutic nutrition, biologically active additives to be introduced in this healthcare institution;

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

e) approval of seven-day menus, a card file 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 advanced training of employees in clinical nutrition;

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

5. The Therapeutic Nutrition Council holds meetings as needed, but at least once every three months.

Appendix No. 4

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

INSTRUCTIONS

ON THE ORGANIZATION OF THERAPEUTIC FOOD

IN MEDICAL AND PREVENTIVE INSTITUTIONS

(as amended by the Orders of the Ministry of Health and Social Development of Russia
No. 624 of 07.10.2005, No. 2 of 10.01.2006, No. 316 of 26.04.2006,
Order of the Ministry of Health of Russia dated June 21, 2013 N 395n)

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

In order to optimize medical 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 the main nutrients and energy value, cooking technology and the average daily set of products.

Previously used diets of the number 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 main standard diet and its variants in a medical institution, in accordance with their profile, they use:

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

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

Unloading diets (tea, sugar, apple, rice-compote, potato, cottage cheese, juice, meat, etc.);

Special diets (potassium, magnesium, probe diet, diets for myocardial infarction, diets for unloading dietary therapy, vegetarian diet, etc.).

Individualization of the chemical composition and 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-made grocery transfers for patients undergoing treatment in a medical institution, and also by using 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 dated 10.01.2006 N 2)

Acquisition of protein composite dry mixtures for clinical nutrition is carried out in accordance with the Instructions on the procedure for use budget classification of the Russian Federation, approved by the 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 Order in state registration does not need) under article 340 of the economic classification of expenditures of the budgets of the Russian Federation "Increase in the cost of inventories" with the assignment of ready-made specialized mixtures for medical nutrition to the section "food (payment for food), including food rations for military personnel and persons equated to them."

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

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

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

Control of the correctness of the diet therapy carried out should be carried out by checking the compliance of the diets received by patients (in terms of a set of products and dishes, cooking technology, chemical composition and energy value) with the recommended characteristics of standard diets and by checking the uniform use of appropriations by quarters of the year.

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

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

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

At the catering department of the medical institution, the production manager (chef, senior cook) controls the compliance with the cooking technology and the output of ready-made dietary dishes, the dietitian, the dietary nurse, the doctor on duty, who allows the issuance of ready-made food to departments, control the quality of ready-made dietary dishes.

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

Table 1

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

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

Standard diets	Number system diets (diets N N 1-15)	Indications for use	General characteristics, cooking	Proteins, incl. animals, g	Fats are common, incl. vegetable, g	General carbohydrates, incl. mono- and disaccharides, g	Energy-geti-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 of the stomach and duodenum in remission. Chronic bowel disease with a predominance of irritable bowel syndrome with predominant constipation. Acute cholecystitis and acute hepatitis in the recovery stage. Chronic hepatitis with mild signs of functional liver failure. Chronic cholecystitis and cholelithiasis. 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 conditions.	A diet with a physiological content of proteins, fats and carbohydrates, enriched with vitamins, minerals, vegetable fiber (vegetables, fruits). When prescribing a diet for diabetic patients, refined carbohydrates (sugar) are excluded. Nitrogenous extractives, table salt (6-8 g / day), foods rich in essential oils, 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 rhythm of nutrition 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 diabetics)	2170- 2400
	1b, 4b, 4c, 5p (I option)	Peptic ulcer of the stomach and duodenum 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. Violations of the function of the chewing apparatus. Acute pancreatitis, stage of fading 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. Sharp snacks, seasonings, spices are excluded; table salt is limited (6-8 g / day). Dishes are cooked boiled or steamed, mashed and not mashed. Food temperature - from 15 to 60-65°C. Free liquid -1.5-2 liters. The rhythm of nutrition 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(II variant), 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. Gluten enteropathy, celiac disease. Chronic pancreatitis in remission. Chronic glomerulonephritis of the nephrotic type in the stage of fading exacerbation without impaired nitrogen excretion of the kidneys. Diabetes mellitus type 1 or 2 without concomitant obesity and impaired nitrogen excretion of the kidneys. Rheumatism with a low degree of activity of the process with a protracted course of the disease without circulatory disorders; 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 fats, complex carbohydrates, and restriction of easily digestible carbohydrates. When prescribing a diet to patients with diabetes mellitus and after resection of the stomach with dumping syndrome, refined carbohydrates (sugar) are excluded. Salt is limited (6-8 g / day), chemical and mechanical irritants of the stomach, biliary tract. Dishes are cooked in boiled, stewed, baked, mashed and unmashed form, steamed. Food temperature - from 15 to 60-65°C. Free liquid - 1.5-2 liters. The rhythm of nutrition is fractional, 4-6 times a day.	110-120 45-50	80-90 30	250-350 30-40	2080- 2690
Reduced Protein Diet Option (Low Protein Diet)	7b, 7a	Chronic glomerulonephritis with a sharp and moderate impairment of the nitrogen excretion function of the kidneys and severe and moderately severe azotemia.	Protein-restricted diet 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), severely restricted table salt(1.5-3 g/day) and liquids (0.8-1 L). Nitrogen extractives, alcohol, cocoa, chocolate, coffee, salty snacks are excluded. Sago dishes, protein-free bread, mashed potatoes, mousses from swelling starch are introduced into the diet. Dishes are cooked without salt, boiled, steamed, not pureed. Food is cooked in a boiled form, steamed, not crushed. The diet is enriched with vitamins and minerals. Free liquid - 0.8-1.0 l. The rhythm of nutrition is fractional, 4-6 times a day.	20-60 15-30	80-90 20-30	350-400 50-100	2120- 2650
Reduced calorie diet option (low calorie diet)	8, 8a, 8o, 9a, 10s	Various degrees of alimentary obesity in the absence of severe complications from the digestive system, blood circulation, and other diseases that require special diets. Type II diabetes mellitus with obesity. Cardiovascular disease in the presence of excess weight.	A diet with a 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 rhythm of nutrition 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 (t) (Introduced by Order of the Ministry of Health and Social Development of Russia dated April 26, 2006 №316)	11	Tuberculosis of the respiratory organs: primary; infiltrative; caseous pneumonia; tuberculoma in decay phase; cavernous; cirrhotic; tuberculous pleurisy, including empyema; bronchi; silicotuberculosis. Extrapulmonary tuberculosis: CNS; peripheral lymph nodes; abdominal organs; genitourinary system; genital; musculoskeletal system; eye; skin and mucous membranes. Tuberculosis in combination with another pathology: HIV; diabetes mellitus; chronic obstructive pulmonary disease; toxicomania and acoholism; hepatitis; professional harm. Tuberculosis associated with multidrug resistance.	A diet with a high content of protein, fat, a physiological amount of complex carbohydrates, a restriction of easily digestible sugars, salt (up to 6 g / day). Diet with high energy value. When prescribing a diet for diabetic patients, refined carbohydrates (sugar) are excluded. Dishes are cooked in boiled, stewed, baked form, with or without mechanical sparing. Food temperature - from 15 to 60-65 degrees C. Free liquid - 1.5-2 liters. The rhythm of nutrition is fractional, 4-6 times a day. When prescribing a diet for diabetic patients, 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 gastric resection with dumping syndrome)	3100 - 3600

Table 1a

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

Ratio natural products nutrition
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,
in red. Order of the Ministry of Health and Social Development of Russia dated April 26, 2006 N 316)

diets	Proteins, incl. animals, g	Fats are common, incl. vegetable, g	General carbohydrates, incl. mono-disaccharides, g	Energy value, kcal
Basic 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 nutrition (mixture protein composite dry)	16-18	8-9	12-14	180-210
Diet option with mechanical and chemical sparing
Chemical composition and 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 (protein composite dry mix)	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 (protein composite dry mix)	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 (protein composite dry mix)	16	8	12	180
A diet option with an increased amount of protein (t) (introduced by Order of the Ministry of Health and Social Development of Russia dated April 26, 2006 N 316)
The chemical composition and energy value of the diet (introduced by Order of the Ministry of Health and Social Development of Russia dated April 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 (composite protein powder mixture)	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

Lost strength. - Order of the Ministry of Health of Russia dated June 21, 2013 N 395n.

Table 2a

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

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

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

Name of products
	gross	net
1	2	3
Rye bread (bran)	150	150
wheat bread	200	200
Wheat flour	50	50
Potato starch	5	5
Macaroni, vermicelli	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
until January 1	120	100
from January 1	125	100
beet
until January 1	94	75
from January 1	100	75
bulb onions	24	20
green onion	18,8	15
parsley dill	20	15
cucumbers, fresh greenhouse tomatoes	30,6	30
	38	25
Fresh fruits	250	250
Dried fruits (compote, raisins, prunes, dried apricots)	26	20
Dried rosehip	15,0	15,0
Juices fruit, vegetable	200	200
Beef (tenderloin)	176,5	150
Chickens I category	28,6	20
Boiled 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, curdled milk, acidophilus, koumiss **	207	200
Milk	300	300
Butter	40	40
Vegetable oil	25	25
Sugar*	50	50
Jam, jam, honey bee, 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

** Koumiss, as a rule, is used in regions where koumiss 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 organizing therapeutic nutrition in medical institutions.

2. The average daily set of products may differ from the set of products provided for 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 in sanatorium treatment

(As amended by the Order of the Ministry of Health and Social Development of Russia dated October 7, 2005 N 624)

Name of products	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
Macaroni, vermicelli	20	20
Cereals (buckwheat, oatmeal, semolina, millet, 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: until January 1 from January 1	115 122	92 92
beet: until January 1 from January 1	55 59	44 44
bulb onions	20	16,8
green onion, greens and parsley root, celery	20	16
parsley, dill, celery	16	12
cucumbers, tomatoes (pumpkin, zucchini, radish, green lettuce, 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 juices, vegetable juices, canned compotes	250	250
Beef (tenderloin), offal (liver, kidney, tongue)	150	127,5
Chickens (turkey)	57	40
Boiled sausage (diabetic, dietary, doctor's), ham, sausages, sausages	10	7,5
Fish, fresh, frozen	140	70
Herring Red fish, stellate sturgeon (sturgeon) Caviar granular	15 7,8 6,2	7,5 5 6
Seafood: sea ​​kale, fish caviar squid, shrimps, trepangi, mussels, crabs	15,2 33	15 30
Cottage cheese	81,5	80
Sour cream, cream	30	30
Cheese, cheese	10	9,2
Chicken egg	1 PC.	1 PC.
Kefir, yogurt, fermented baked milk, curdled milk, acidophilus	103,5	100
Milk	317	300
Butter	50	50
Vegetable oil	30	30
Mayonnaise	5	5
Sugar*	50	50
Jam, jam, honey bee, waffles, cookies, marshmallows, marshmallows, sweets	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 diabetics. They are equivalently replaced by specialized dietary products that do not contain sucrose.

Notes:

1. The average daily set of products may differ from the set of products provided for 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 preventive) nutrition.

Table 4

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

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, beans, pasta	35	50	65	80
Potato	150	250	300	350
Various vegetables and herbs	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 by-products)	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 packages for children,
affected by radiation exposure
being treated in sanatoriums
institutions of various profiles (except for tuberculosis)

Products (g, ml gross)	Amount per day per child aged
	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
Various vegetables and herbs	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 dishes

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

Name of replacement products	Mass of products, gross, kg	Name of replacement products	Equivalent weight of products, gross, kg	Culinary use
1	2	3	4	5
Eggs without shell	1,00	Egg melange frozen	1,00	In egg dishes, casseroles, flour products
Same	1,00	Dry egg mix	0,35	Same
Same	1,00	Egg powder	0,28	Same
Unsalted cow butter, "Vologda"	1,00	Peasant oil	1,13	In culinary products and dishes (except for dressing dishes on vacation)
Same	1,00	Amateur cow butter	1,06	Same
Same	1,00	Salted cow butter (with a reduction in the amount of salt in the recipe by 0.02 kg)*(2)	1,00	In minced meat, pancakes, pancakes
Same	1,00	Melted cow butter	0,84	In minced meat, pancakes, pancakes and for seasoning 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	Sunflower oil, unrefined	1,00	In marinades, some sauces, cold, vegetable, fish dishes, flour products
	1,00	Cow's milk, pasteurized, non-fat (with an increase in the bookmark in the formula of unsalted cow butter per 0.04 kg)	1,00
Cow's milk, pasteurized, whole	1,00	Whole cow's milk powder	0,12	In soups, sauces, egg dishes, flour products, vegetables, sweet dishes, drinks, etc.
Cow's milk, pasteurized, whole	1,00	Dry skimmed cow's milk (with an increase in the amount of unsalted cow butter in the recipe by 0.04 kg)	0,09	In soups, sauces, egg dishes, sweet dishes, flour products, cereals
Same	1,00	Dried cream (with a decrease in the bookmark in the recipe of unsalted cow butter by 0.042 kg)	0,16	In milk porridge
Same	1,00	Whole milk condensed with sugar (with a reduction in the amount of sugar in the recipe by 0.17 kg)	0,38	In sweet foods, drinks
Same	1,00	Sterilized condensed milk in jars	0,46	In soups, sauces, sweet dishes, flour products and drinks
Same	1,00	Condensed cream with sugar (with a decrease in the bookmark in the recipe of 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, kissels, mousses, jelly
Same	1,00	refined powder	1,00	In sweet dishes, casseroles, puddings
Jam, jam	1,00	Fruit and berry marmalade (carved)	0,84	in sweet dishes
Same	1,00	Seedless jam	1,00	Same
Dry potato starch (20% moisture)	1,00	Potato starch (raw 50% moisture)	1,60	In kissels, sweet soups
Potato starch	1,00	Corn starch	1,50	In milk jelly, jelly
Pressed baking yeast	1,00	Dry baker's yeast	0,25	For the preparation of drinks, flour products
Tea black long leaf not packaged	1,00	Tiled black tea	1,00	For making drinks
Natural coffee, roasted	1,00	Coffee natural instant	0,35	Same
Vanillin	1,00	Vanilla sugar	20,0	in sweet dishes
Same	1,00	vanilla essence	12,7	Same
Gelatin	1,00	agaroid	0,70	In sweet jellied dishes
Green peas (canned)	1,00	Fresh vegetable peas (shoulder)	0,82	In cold dishes, soups, vegetable dishes, side dishes
Same	1,00	Vegetable beans (shoulder) fresh	0,82	Same
Same	1,00	Fresh frozen green peas	0,71	Same
Dill, parsley, fresh celery	1,00	Salted greens of dill, parsley, celery sprigs (with a decrease in the amount of salt in the recipe by 0.29 kg)	1,00	For flavoring broths, soups, sauces
Same	1,00	Dill, parsley, celery, chopped salted (with a decrease in the amount of salt in the recipe by 0.22 kg)	0,76	Same
Same	1,00	Dill, parsley, celery, sprigs, frozen	0,76	Same
Parsnips, parsley, celery, fresh root	1,00	Dried white parsley, celery and parsnips	0,15	In soups, sauces, when stewing meat, fish, vegetables
Fresh sorrel	1,00	Sorrel puree (canned)	0,40	In soups using sorrel
spinach fresh	1,00	Spinach puree (canned)	0,40	In soups with spinach, in vegetable dishes
Tomatoes (fresh)	1,00		0,46	In soups, sauces and when stewing vegetables
Same	1,00		0,37	Same
Same	1,00	Natural tomato juice*(4)	1,22	Same
Tomatoes (fresh)	1,00	Canned food. Natural whole tomatoes (round fruits)	1,70	In cold dishes and side dishes
Same	1,00	Canned food. Natural whole tomatoes (plum fruits)	1,42	Same
fresh leek	1,00	fresh green onion	0,95	In soups, cold dishes, side dishes, vegetable dishes
Tomato puree with a solids content of 12%	1,00	Natural tomato juice	2,66	In soups, sauces and when stewing meat, fish, vegetables, etc.
Same	1,00	Tomato puree with a solids content of 15%	0,80	Same
Same	1,00	Tomato paste with a solids content of 25-30%	0,40	Same
Tomato puree with a solids content of 12%	1,00	Tomato paste with a solids content of 35-40%	0,30	Same
Same	1,00	Salted tomato paste with a solids content of 37% (with a reduction in the amount of salt in the recipe by 0.03 kg)	0,30	Same
fresh apples	1,00	Apples whole, halves, quarters (blanched in sugar syrup) quick-frozen	0,8/0,73*(5)	in sweet dishes
Cowberry fresh	1,00	fresh cranberries	1,00	In cabbage salads and in 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	Same
Nut kernel, sweet almond	1,00	Kernel of walnuts, hazelnuts, peanuts	1,00	In sweet dishes, puddings
Citric acid food	1,00	Food tartaric acid	1,00	In dishes where citric acid is used
Same	1,00	Lemon juice	8,00	Same

Notes:

*(1) When using butter for dressing when serving dishes, the amount of replacement and replacement butter 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) The calculation of the replacement rate is made in accordance with GOST.

*(5) The numerator is the weight of apples when the semi-finished product is defrosted in air, the denominator is the weight of apples when the semi-finished product is defrosted in sugar syrup.

Table 7

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

Replacing products for proteins and carbohydrates

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

Name of products	Number of products in net, g	Chemical composition			Add to the daily diet (+) or exclude from it (-)
		proteins, g	fats, g	carbohydrates, g
1	2	3	4	5	6
Bread replacement (for protein and carbohydrates)
Wheat bread from flour I c.	100	7,5	2,9	51,4
Rye bread simple pan	125	7,62	1,5	49,87
Wheat flour I s.	70	7,42	0,91	48,3
Macaroni, vermicelli I p.	70	7,7	0,91	49,35
Semolina	75	7,72	0,9	52,95
Potato replacement (by carbohydrates)
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 b/c	370	6,66	0,37	17,39
Macaroni, vermicelli I p.	25	2,75	0,32	17,62
Semolina	25	2,57	0,25	17,65
Wheat bread from flour I c.	35	2,62	1,01	17,99
Rye bread simple pan	45	2,74	0,54	17,95
Replacing fresh apples (by carbohydrates)
fresh apples	100	0,4	0,4	9,8
Dried apples	15	0,33	0,01	8,85
Dried apricots (pitted)	18	0,94	0,05	9,18
Prunes	15	0,34	0,1	8,63
Protein replacement for milk
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.	15	2,79	2,4	-
Beef II class	15	3,0	1,47	-
beef tenderloin	15	3,03	0,42	-
Cod fish)	20	3,2	0,12	-
Specialized food products (protein composite dry mix)	7	2,8	1,4	2,1
Meat replacement (for protein)
Beef I.	100	18,6	16,0	-
Beef II class	90	18,0	8,82	-	oil + 7 g
beef tenderloin	90	18,18	2,52	-	butter + 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 (protein composite dry mix)	45	18,0	9,0	13,68
Fish replacement (by protein)
Cod fish)	100	16,0	0,6	-
Beef I.	85	15,81	13,6	-	oil - 13 g
Beef II class	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 (protein composite dry mix)	40	16,0	8,0	12,2
Cottage cheese replacement (by protein)
Bold cottage cheese	100	18,0	9,0	3,0
Beef I.	100	18,6	16,0	-	oil - 7 g
Beef II class	90	18,0	8,82	-
beef tenderloin	90	18,18	2,52	-	oil + 6 g
Cod fish)	110	17,6	0,66	-	butter + 8 g
Chicken egg	140	17,78	16,1	0,98	oil - 7 g
Specialized food products (protein composite dry mix)	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.	30	5,58	4,8	-
Beef II class	25	5,0	2,45	-
beef tenderloin	25	5,05	0,7	-
Cod fish)	35	5,6	0,73	-
Specialized food products (protein composite dry mix)	12,7	5,08	2,5	3,8

The procedure for issuing meals

for patients in medical institutions

1. The extract of nutrition is carried out by a dietary nurse under the guidance of a dietitian.

In medical institutions where there is no position of a dietitian, nutrition is issued by a dietitian nurse under the supervision of a doctor responsible for clinical nutrition.

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

3. Accounting for diets is maintained by ward nurses, who daily report to the head nurse of the department the number of patients and their distribution by diet. On the basis of this information, the senior nurse of the department draws up the form N 1-84 "Portion for the nutrition of patients", which is signed by her, the head of the department and transferred to the catering unit by the dietary nurse.

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

5. Based on the "Summary information" dietary nurse with the participation of the head. production (chef) and accountant under the guidance of a dietitian draws up a menu-layout in the form N 44-MZ for the nutrition of patients the next day.

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

6. Based on the final data of form N 44-MZ, a "Requirement for the issuance of food products from a warehouse (pantry)" is issued in accordance with form N 45-MZ in two copies.

7. The laying of food products in the boiler is carried out in the presence of a dietitian (dietary 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 carried out according to the form N 23-MZ ("Vallet sheet for the departments of food rations for patients"), which is filled in by the dietary nurse in one copy. When issuing breakfasts, lunches and dinners, branch employees sign for their receipt. The statement is signed by the dietary nurse and head. production (chef).

Buffet products (butter, bread, tea, salt, etc.) are issued 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 (requirement) to the warehouse (pantry) in the form N 434. Food stuffs put into the boiler are not subject to return.

10. Additional meals prescribed in the department for dietary rations are drawn up in two copies, signed by the attending physician, head of the department and approved by the head physician of the medical institution. The first is transferred to the catering unit, the other is stored in the medical history.

11. For each dish prepared in a medical institution, a layout card is drawn up in form N 1-85 in two copies: one copy is kept by the accountant, the second is kept by the dietary nurse (on the back of the card, the technology for preparing the dish is described).

The procedure for quality control of prepared food in a medical institution

1. The control of prepared food before issuing it 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 institution, and is also carried out by a dietitian, dietary nurse, head. production (or chef) regardless of the sample produced by the doctor on duty.

2. Checking the finished food at the catering unit before issuing it 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 boiler and the number of ordered servings and the volume of one serving. The weight of second courses (cereals, puddings, etc.) is determined by weighing the entire quantity in a 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 servings and set average weight one serving. Weight deviations from the norm should not exceed 3%;

b) by sampling a decorated dish of one of the diets used.

3. The results of the food sample are recorded by the doctor on duty in the journal of prepared food (form N 6-lp).

4. Selection ready meals 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 dietitian or a dietitian nurse.

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

1. mechanical equipment used for primary processing of products, it includes:

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

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

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

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

e) machines for cutting bread, egg cutters;

f) beater for liquid mixtures.

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

a) cooking equipment includes cooking pots, sauce pots, steamers, egg and sausage boilers;

b) frying equipment includes electric frying pans, electric crucibles, electric stoves, microwave ovens. Oven 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, racks, carts, scales, cabinets for storing kitchen utensils and appliances, chests, cutting decks;

b) pots, buckets, baking sheets, frying pans, sieves, vessels, kettles;

c) inventory: knives, forks, spatulas, mortars, molds, strainers, skimmers, etc.

4. Refrigeration equipment is represented by refrigerating chambers and refrigerated cabinets.

5. The premises of the pantry at the departments of medical institutions should be provided with:

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

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

c) washing disinfectants;

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

f) a cabinet for storing household equipment;

g) a food warmer or an electric stove for heating food;

h) a table with a hygienic covering for distributing food;

i) a table for dirty dishes;

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

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

Responsibility for the right equipment the catering and canteen departments of the medical institution are carried out by the deputy chief physician for the administrative and economic part and the dietitian.

Transportation of prepared food

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

b) for the transportation of prepared food to the pantry departments of the hospital, thermoses, thermos trolleys, food warmer trolleys or tightly closed dishes are used.

Sanitary and hygienic regime of the catering department and pantry

1. In the food blocks of medical 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 regulations for catering establishments;

Sanitary rules on the conditions and terms of storage and sale of especially perishable products;

Requirements for mandatory preventive and medical examinations of catering, distributing and buffet workers (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 institution. Washing of dishes is carried out only in the washing cupboards of the departments in compliance with the disinfection of dishes.

The 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.

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

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

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

After each distribution of food, the premises of the pantry and dining room are thoroughly cleaned using disinfectant solutions.

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

The staff of the catering unit and pantry is obliged to observe the rules of personal hygiene. Before visiting the toilet, the staff must take off their bathrobe, after the visit, they must brush their hands with disinfectants or laundry soap.

Responsible for compliance sanitary requirements when preparing and dispensing ready-made food in the catering department is the head. production (chef), a dietary nurse, a dietitian, and in the department - barmaids and senior nurses.

Letter No. 2510/2877-04-32 of 07.04.2004 of the Ministry of Health of Russia states that the duration of storage of daily samples of prepared 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 serving or 100 - 150 g of each dish, placed in a clean boiled for 15 minutes. labeled dishes with a lid, which are stored in a separate refrigerator for a day.

List of documentation of the catering unit for issuing meals and monitoring the quality of prepared food in medical institutions

Form N 1-84

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

Portioner

for the nutrition of patients "__" __________ 20__

Head Branch (signature)

Art. honey. branch sister (signature)

Honey. dietary sister of the department (signature)

Form N 22-MZ

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

Name of institution __________________________________________________

Summary information on the presence of patients on food

at ___ hours "__" _______ 20__

(Back side)

Individual and additional meals
(as well as the nutrition of mothers who are in a medical institution with babies)

Form N 23-MZ

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

Handout list

On vacation to food ration departments

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

20__

Dietary nurse ______ Head of production (chef) _____

Form N 1-85

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

Name of the medical institution ______________________________________________

I approve: ____________

Head of institution

Layout card N

Name of the dish _________________________________________________________

Indication for use _________________________________________________

Product name	Gross	Net	Chemical composition				Price
			Proteins, g	Fats, g	Carbohydrates, g	calories, kcal
Finished meal weight:

Dietitian (dietary nurse)

Production manager (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)

Name of institution _________________________________________________

Layout menu for cooking meals on ________________________

patients on "__" ___________ 20__

Day of the week

Name

How many dishes

N dishes by cartoteca

Name of products, in grams

Output of ready meals

M I With O

I th c A

T V O R O G

M O l O To O

WITH A X A R

Fruit juice

Sour cream

Butter

Vegetable oil

TO A R T O f e l b

TO A P at With T A

M at To A

X l e b

Green pea

I b l O To And

Yeast

L And m O n

Standard diets

Reception of food and dishes included in it

B at f e T

TO at X n I

B at f e T

TO at X n I

B at f e T

TO at X n I

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 book.

II. A note on the transition to work in other institutions.

III. The results of the medical examination.

IV. The results of the study on tuberculosis.

V. The results of the study on bacillus carrying.

VI. The results of the study on helminthism.

VII. Marks on the postponed infectious-intestinal diseases.

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

IX. Vaccination record.

X. Special marks of sanitary supervision about this employee(breaking the rules

personal hygiene, sanitary supervision requirements, etc.).

Form 2-lp

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

Magazine "Health"

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

Journal of quality control of finished food (defective)

* - when replacing individual dishes in breakfast, lunch or dinner, make an appropriate entry

Appendix 5

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

INSTRUCTIONS FOR ORGANIZING ENTERAL NUTRITION

IN MEDICAL AND PREVENTIVE INSTITUTIONS

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

Enteral nutrition is a type of nutritional therapy in which nutrients are introduced through a gastric (intestinal) tube when it is impossible to adequately meet the energy and plastic needs of the body 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 nutritional 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 dated April 26, 2006 N 316)

The purchase of nutritional mixtures for enteral nutrition is carried out in accordance with the Guidelines 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 N 01 / 32-EZ, the Order does not need state registration) under article 340 of the economic classification of expenditures of the budgets of the Russian Federation "Increase in the cost of inventories" with attribution nutrient 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 dated April 26, 2006 N 316)

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

Indications for the use of enteral nutrition

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

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

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

Radiation and chemotherapy in oncological diseases;

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

Nutrition in the pre- and postoperative periods;

Trauma, burns, acute poisoning;

Complications of the postoperative period (fistulas of the gastrointestinal tract, sepsis, failure of anastomotic sutures);

Infectious diseases;

Mental disorders: psychiatric anorexia, severe depression;

Acute and chronic radiation injuries;

Widespread and generalized forms of tuberculosis with seeding and decay, with significant weight loss, tuberculosis in combination with HIV in III B and further stages; pre- and postoperative periods; local forms of tuberculosis in young children and in adolescence.

Contraindications to the use of enteral nutrition

Intestinal obstruction;

Acute pancreatitis;

Severe forms of malabsorption.

Assessment of malnutrition

When prescribing enteral nutrition, as well as when choosing the composition of nutrient mixtures and determining the dosage, it is necessary to control the degree of nutritional status disorders. At the first stage, with the help of history taking 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 assessment of the state of nutrition is carried out 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 skin-fat fold of the triceps

b) biochemical indicators:

total protein
- albumin
- transferrin

c) immunological indicators:

Total number of lymphocytes

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

Observation map
patient receiving enteral nutrition

(insert in the medical record of an inpatient, accounting form N 003/U)

Name of the medical institution ________________________

N medical history _____________________________________________________________

FULL NAME. __________________________ Gender _____ Age _____________________

Height ______________________ Body weight at admission _____________ (kg),

at discharge ______________ (kg).

Changes in body weight over the past 6 months ______________________________

Clinical diagnosis:_____________________________________________________

_________________________________________________________________________

N	Indicators	Initial data	After treatment	Standards	Malnutrition
					light	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	KZhST, 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, thousand			>1,8	1,8-1,5	1,5-0,9	<0,9
	Sum of points			24	24-16	16-8	8

BMI - body mass index: weight / height m2

KZhST - skin-fat fold of the triceps.

For enteral nutrition, it is necessary to determine the energy needs of the body. It is necessary to determine the energy consumption using direct or indirect calorimetry methods. If it is impossible to carry out the indicated research methods, the assessment of energy needs can be carried out by calculation using the appropriate equations:

according to the Harris-Benedict equation:

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

where DRE - actual energy costs (kcal / day);

OEO - basic energy metabolism;

FA - activity factor; FT - trauma factor;

TF - temperature factor; DMT - underweight.

OEE (men) \u003d 66 + (13.7 x BW) + (5 x R) - (6.8 x B)

OEE (women) \u003d 655 + (9.6 x MT) + (1.8 x R) - (4.5 x B)

where MT - body weight (kg);

P - height (cm);

B - age (years).

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

Energy supply of the main nutrients:

1 g of 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 diseases (Table 9).

The choice of the composition of mixtures for enteral nutrition

When choosing a formula for enteral nutrition, you should be guided by the list of enteral formulas below that are approved for use by the Russian Ministry of Health.
(As amended by the Order of the Ministry of Health and Social Development of Russia dated April 26, 2006 N 316)

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

With normal needs and the preservation of the functions of the gastrointestinal tract, standard nutrient mixtures are prescribed.

With increased protein and energy requirements or fluid restriction, high-calorie nutrient mixtures are prescribed.

Pregnant and breastfeeding women should be given nutritional formulas designed for this group.

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

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

In case of impaired lung function, nutrient mixtures with a high content of fat and a low content of carbohydrates are prescribed.

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

In case of liver dysfunction, nutrient mixtures with a low content of aromatic amino acids and a high content of branched-chain amino acids are prescribed.

With partially impaired functions of the gastrointestinal tract, nutrient mixtures based on oligopeptides are prescribed.
(As amended by the Order of the Ministry of Health and Social Development of Russia dated April 26, 2006 N 316)

With a non-functioning intestine (intestinal obstruction, severe forms of malabsorption), the patient must be given parenteral nutrition.

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

Table 8

to Instructions for the organization of enteral nutrition
in medical institutions

Requirements for basic nutrients (proteins, fats, carbohydrates)
depending on the degree of malnutrition

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

Table 9

To Instructions for the organization of enteral nutrition
in medical institutions

The need for protein in certain diseases

Methods of administering enteral nutritional mixtures

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

1. The use of nutrient mixtures in the form of drinks through a tube in small sips;

2. Tube nutrition using nasogastric, nasoduodenal, nasojejunal and dual-channel probes (for aspiration of gastrointestinal contents and intra-intestinal administration of nutrient mixtures, mainly for surgical patients).

3. By imposing a stoma: gastro-, duodeno-, jejuno-, iliostomy. 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	Days 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
Thickness of the fold over the triceps, mm
Shoulder muscle circumference, cm
Indicators	Date of measurement
Laboratory data
- hemoglobin
- erythrocytes
- leukocytes
- lymphocytes
- hematocrit
- blood osmolality
- total protein
- albumin
- transferrin
- urea
- creatinine
- cholesterol
- glucose
- potassium
- sodium
- calcium
- chlorides
- ALT
- ASAT
- bilirubin
Biochemistry of urine:
- total nitrogen
- aminazot
- urea
- creatinine

MINISTRY OF HEALTH
Khabarovsk Territory

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

I declare:

1. .

I order:

1. Heads of health management bodies of municipalities, medical and preventive institutions of the region:
1.1. To accept for execution the Order of the Ministry of Health of the Russian Federation of August 5, 2003 N 330 "On measures to improve nutrition in medical institutions of the Russian Federation", bring it to the attention of specialists of subordinate medical institutions.
1.2. Organize a seminar for medical workers of subordinate institutions to study the above Order before 10.06.2004.
1.3. To ensure the introduction of a new range of diets, to use in therapeutic and enteral nutrition with the individualization of the chemical composition and calorie content (standard diets, with mechanical and chemical sparing, with an increased amount of protein), a decrease or increase in buffet products, biologically active food supplements (including soy products, bread from sprouted grains or with lamidan) and ready-made specialized mixtures.
1.4. Fill vacancies with dieticians.
1.5. To amend the existing Regulations on the Council for Clinical Nutrition, on the organization of the activities of a dietitian, a nurse in a dietary medical and preventive institution.
1.6. Submit an application to the Ministry of Health of the Territory about the need to conduct training on the basis of the Institute for Advanced Training of Health Professionals of the Ministry of Health of the Khabarovsk Territory for doctors and paramedical workers, to ensure that they are sent to specialized courses in the system of postgraduate education.
2. First Deputy Minister of Health of the Khabarovsk Territory Tropnikova V.M. to provide for in the programs of postgraduate training of medical workers the issues of organizing therapeutic nutrition in medical institutions.
3. To take into account the Order of the Ministry of Health of the Russian Federation of February 12, 2004 N 95 "On the cancellation of the order of April 23, 1985 N 540 and of June 14, 1989 N 369".
4. Information on the execution of this order must be submitted by 01.10.2004.
5. To impose control over the execution of this order on the Deputy Minister of Health of the Khabarovsk Territory A.Ya. Derkach.

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

With changes and additions from:

For the application of this order, see the letter of the Ministry of Health of the Russian Federation of April 7, 2004 N 2510 / 2877-04-32 and the letter of the Ministry of Health and Social Development of the Russian Federation of July 11, 2005 N 3237-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 the Decree of the Government of the Russian Federation of 10.08.1998 N 917 *, improve the organization of clinical nutrition and increase the effectiveness of its use in the complex treatment of patients, I order:

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

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

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

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

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

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

Order 330 on Clinical Nutrition

MINISTRY OF HEALTH OF THE RUSSIAN FEDERATION

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

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

In order to implement the Concept of State Policy in the field of healthy nutrition of the population of the Russian Federation for the period up to 2005, approved by the Decree of the Government of the Russian Federation dated 10.08.1998 No. 917 *, improve the organization of therapeutic nutrition and increase the effectiveness of its use in the complex treatment of patients, I order:

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

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

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

Minister
Yu.L. Shevchenko

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

POSITION
ABOUT THE ORGANIZATION OF THE ACTIVITIES OF A NUTRITIONAL DOCTOR

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

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

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

The dietitian must:

advise doctors of departments on the organization of medical nutrition;

advise patients on therapeutic and rational nutrition;

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

analyze the effectiveness of therapeutic nutrition;

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

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

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

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

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

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

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

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

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

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

POSITION
ON ORGANIZATION OF MEDICAL ACTIVITIES
SISTERS DIETARY

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

A dietary nurse works under the guidance of a dietitian.

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

The dietary nurse is required to:

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

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

exercise control over the correctness of the laying of products during the preparation of dishes and the rejection of finished products, take samples of the finished food;

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

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

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

maintain medical records;

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

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

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

POSITION
ABOUT THE THERAPEUTIC NUTRITION COUNCIL
TREATMENT AND PREVENTIVE INSTITUTIONS

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

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

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

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

Tasks of the Council for Therapeutic Nutrition:

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

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

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

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

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

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

Previously used diets of the number system (diets No. 1-15) are combined or included in the system of standard diets, which are prescribed for various diseases depending on the stage, severity of the disease or complications from various organs and systems (Table 1).

Along with the main standard diet and its variants in a medical institution, in accordance with their profile, they use:

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

Individualization of the chemical composition and 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-made grocery transfers for patients undergoing treatment in a medical institution, and also by using 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 the Russian Federation dated 10.01.2006 No. 2)

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

The purchase of dry composite protein mixtures for clinical nutrition is carried out in accordance with the Instructions on the procedure for applying the budget classification of the Russian Federation, approved by Order of the Ministry of Finance of the Russian Federation of December 21, 2005 No. 152n (in accordance with the letter of the Ministry of Justice of the Russian Federation of January 10, 2006 N 01 / 32-EZ The order does not need state registration) under article 340 of the economic classification of expenses of the budgets of the Russian Federation "Increase in the cost of inventories" from carrying ready-made specialized mixtures for therapeutic 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 dated April 26, 2006 No. 316)

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

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

Control of the correctness of the diet therapy carried out should be carried out by checking the compliance of the diets received by patients (in terms of a set of products and dishes, cooking technology, chemical composition and energy value) with the recommended characteristics of standard diets and by checking the uniform use of appropriations by quarters of the year.

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

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

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

At the catering department of a medical institution, the head of production (chef, senior cook) controls the compliance with the cooking technology and the output of ready-made dietary dishes, the dietitian, the dietary nurse, the doctor on duty, who allows the issuance of ready-made food to departments, control the quality of ready-made dietary dishes.

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

Table 1
to the Instructions for Organizing
preventive institutions

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

www.santegra.spb.ru

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

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

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

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

Approaches to the creation of dry composite protein mixtures and their recipes were developed back in the 70s of the last century by Academician A.A. Pokrovsky. These products are made on the basis of whey milk proteins with the inclusion of lecithin, polyunsaturated fatty acids, dietary fiber, vitamins and minerals, maltodextrin (source of carbohydrates).
Dry composite protein mixes include a well-balanced and easily digestible protein, the source of which is not soy, but milk whey proteins. At the same time, they do not contain animal fat, the excess consumption of which leads to the development of atherosclerosis and overweight.
The effectiveness of their inclusion in dietary dishes for many cardiovascular diseases, diabetes mellitus, liver diseases, metabolic disorders and other diseases is confirmed by the results of clinical trials that were conducted for two years at the Federal State Budgetary Institution "Nutrition Research Institute" of the Russian Academy of Medical Sciences, the Federal State Budgetary Institution "Central Research Institute of Tuberculosis" of the Russian Academy of Medical Sciences, etc.
Dry composite protein mixes are produced in accordance with GOST R 53861-2010 “Products of dietary (therapeutic and preventive) nutrition. Mixes proteinaceous composite dry. General technical conditions".
Mixtures are included in the State Register and are used as a component for the preparation of therapeutic and preventive nutrition for children from 3 years of age and adults, and workers employed in jobs with harmful and especially harmful working conditions.
Composite protein powder mixtures were introduced into medical and sanatorium nutrition in accordance with the previous standards for six standard diets, which were approved by the Order of the Ministry of Health of Russia in 2003 (Order of the Ministry of Health of Russia dated August 5, 2003 N 330 "On measures to improve clinical nutrition in medical institutions of the Russian Federation") with changes as of April 26, 2006, introduced by orders of the Ministry of Health and Social Development of Russia No. 2 dated 10.01.2006 and No. 316 dated April 26, 2006

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

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

The draft order was publicly discussed on the Unified Information Disclosure Portal on the preparation by federal executive authorities of draft regulatory legal acts and the results of their public discussion. There were no comments or suggestions for the draft order.

www.rosminzdrav.ru

Organization of medical nutrition



The process of organizing medical nutrition in medical institutions of our country must be considered from the standpoint of the current federal legislation. For the first time in the Russian legislation, the Federal Law of November 21, 2011 No. 323-FZ “On the Fundamentals of Protecting the Health of Citizens in the Russian Federation” defines the rules governing the basics of the organization of clinical nutrition.

Organization of medical nutrition at the federal level

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

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

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

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

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

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

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

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

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

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

• indications for the use of enteral nutrition;
• contraindications to the use of enteral nutrition;
• assessment of malnutrition;
• observation card of a patient receiving enteral nutrition (insert in the medical record of an inpatient, registration form 003/U);
• methodology for determining the energy needs of the body;
• the choice of the composition of mixtures for enteral nutrition;
• requirements for basic nutrients (proteins, fats, carbohydrates) depending on the degree of malnutrition;
• the need for protein in certain diseases;
• ways of introducing enteral nutritional mixtures.

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

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

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

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

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

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

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

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

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

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

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

Seven Day Consolidated Menu

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

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

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

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

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

Layout card

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

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

Diet nomenclature

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

Special diets are assigned to a specific clinical and statistical group of patients, the condition of which requires the exclusion of certain foods from the therapeutic diet, are formed on the basis of standard diets in accordance with the nosological form of the disease, the phase of the disease. Protein correction of the diet is carried out with dry protein composite mixtures.

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

Accounting and reporting documentation

A number of documents that must be kept in a mandatory manner in a medical institution refer to accounting and reporting documents. In medical institutions, in order to optimize work, automated document management systems are being introduced that ensure the implementation of evidence-based principles of nutrition.

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

The main legal document, on the basis of which food products are issued from the warehouse to the kitchen for cooking and appropriations for food are spent, is layout menu(form No. 44-MZ, order No. 330 dated 05.08.2003). The last digit in the layout menu is entered by the accounting officer, who calculates the total number of all products needed to prepare all the dishes for their release from the warehouse.

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

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

If the number of patients changes compared to the menu layout data (or menu requirements) by more than three people, the dietary nurse prepares "Information on the movement of patients". In accordance with this document, it draws up in the form No. 434-fur (with an increase in the number of patients) "Demand for the warehouse" to receive additional products based on the main version of the standard diet. If the number of patients decreases compared to the previous day, then the products not used for cooking are returned to the warehouse in the same form with the indication “Return” (except for the products already put into the boiler when preparing breakfast).

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

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

Cumulative statement reflects the actual consumption of all products for the past month. The accountant must prepare it by the 10th day of the next month and submit it to a dietitian or a person responsible for organizing clinical nutrition for analysis of the implementation of natural food norms. By the 15th day, a nutritionist or a person responsible for organizing therapeutic nutrition is obliged to inform the head doctor about the state of fulfillment of food standards and, if there are deficiencies, take measures to eliminate them.

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

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

Each food service worker must have:

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

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

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

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

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

The need for GOSTs

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

Federal Law No. 184-FZ of December 27, 2002 "On Technical Regulation" the principles of standardization in the Russian Federation are defined, the rules for the application of technical regulations and national standards of the Russian Federation (GOST R 1.0-2004 "Standardization in the Russian Federation. Basic provisions") are established. This document states that technical regulations, i.e. federal laws that establish safety requirements, are mandatory for application to all products.

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

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

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SanPiNs and resolutions

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

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

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

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

“Technical regulation is a document adopted by an international treaty of the Russian Federation subject to ratification in accordance with the procedure established by the legislation 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 by federal law, or by a decree of the President of the Russian Federation, or by a decree of the Government of the Russian Federation, or by a regulatory legal act of the federal executive body for technical regulation, and establishes mandatory requirements for the application and implementation of requirements for objects of technical regulation (products or products and related requirements for products to design processes [including surveys], production, construction, installation, commissioning, operation, storage, transportation, sale and disposal)”.

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

At the level of the subject of the Federation

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

In accordance with Art. 39 of the Federal Law of the Russian Federation of November 21, 2011 No. 323-FZ “On the Fundamentals of Protecting the Health of Citizens in the Russian Federation” Order of the Government of the Russian Federation of October 25, 2010 No. 1873-r “On Approval of the Fundamentals of the State Policy of the Russian Federation in the field of healthy nutrition of the population for the period up to 2020” it is recommended that the executive authorities of the constituent entities of the Russian Federation take into account the provisions of the Fundamentals of the State Policy of the Russian Federation in the field of healthy nutrition of the population for the period up to 2020 when forming and implementing regional programs for socio-economic development.

Decree of the President of the Russian Federation No. 598 dated May 7, 2012 “On Improving the State Policy in the Sphere of Healthcare” 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 of the population for the period up to 2020”.

In order to fulfill the said regulatory legal acts established by the Government of the Russian Federation, as well as orders established by the Ministry of Health and Social Development of Russia, and in order to unify the requirements for the organization of dietary (therapeutic and preventive) nutrition, standardize the average daily food sets and the seven-day menu in medical organizations in Moscow, the Moscow Health Department issued Order No. methodological recommendations "Card file of dishes of dietary (therapeutic and preventive) nutrition of an optimized composition for children", which regulates the algorithm for organizing dietary (therapeutic and preventive) nutrition in medical organizations of the city.

This order uses the norms of physical needs developed by Rospotrebnadzor (G. G. Onishchenko), the norms of protein correction of ready-made meals, calculated in accordance with the order of the Ministry of Health and Social Development of Russia No. 330. In accordance with the developments of the Federal State Budgetary Institution "Research Institute of Nutrition" of the Russian Academy of Medical Sciences, optimized average daily food sets are given. Thanks to the measures taken, the unification of requirements for the organization of dietary (therapeutic and preventive) nutrition, the standardization of average daily food sets and the seven-day menu in medical organizations in Moscow, heads of medical institutions can reasonably and efficiently spend financial resources. In addition, it became necessary to introduce non-departmental control over the expenditure of funds for medical nutrition and the quality of diet in medical institutions into the work of the Department of Health.

In some constituent entities of the Russian Federation, documents have been developed for the implementation of the main directions of the Order of the Ministry of Health of Russia dated August 5, 2003 No. 330 “On measures to improve therapeutic nutrition in medical institutions of the Russian Federation” in accordance with the Procedure for providing medical care to the population in the profile “dietology” approved by the Ministry of Health and Social Development of Russia (see Table 3). The full texts of the documents presented in the table can be found on the website www. praktik-dietolog.ru in the "Legislative framework" section.

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

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

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

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

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

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

   • technical support for the implementation of therapeutic diets;
   • food quality;
   • qualification of medical personnel involved in catering;
   • production, sales conditions, food quality;
   • accounting and reporting documentation used in the system of dietetics;
   • economic aspects of standardization, food procurement system, personalized accounting.

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

   At the level of a medical institution

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

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

   Diet meals are organized and carried out by a dietitian. The execution technology is associated with the appointment of a certain diet to the patient in accordance with the approved diet nomenclature. The organization of the catering department, the formation of nutritional therapeutic diets (diets) for various clinical and statistical groups of patients on the basis of standard diets and special and individual diets developed on their basis using food products in the preparation of meals, including dietary, specialized (composite protein powder mixtures) and baby food, is the basis for the formation of a therapeutic 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 the nutritional support team. In its absence, this task falls on doctors, as a rule, resuscitators, who specialize 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 for organizing and conducting enteral nutrition is regulated in Appendix No. 5 of the instructions for organizing enteral nutrition in medical institutions (approved by order of the Ministry of Health of Russia dated August 5, 2003 No. 330) (as amended on April 26, 2006). For enteral nutrition, enteral mixtures are used, which completely replace one or more meals, are used only for medical reasons when it is impossible to adequately meet the energy and plastic needs of the body in a natural way in a number of diseases. The extract of enteral mixtures from the food warehouse is carried out on the basis of Form No. 22-MZ "Information on individual and additional nutrition" after a preliminary calculation of the patient's need for the main ingredients, filling out an observation card for a patient receiving enteral nutrition (insert in the medical record of an inpatient, registration form No. 003/U).

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

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

   Enteral and parenteral nutrition are artificial types of nutrition that are used only for medical reasons when it is impossible to adequately meet the energy and plastic needs of the body naturally in a number of diseases and are presented in a number of reference manuals and recommendations for nutritional support in intensive care and resuscitation. These sections are not within the competence of a dietitian, they expand the possibilities of introducing nutrients into the patient's body using alternative methods (through the vascular bed) or specially created artificial balanced nutritional mixtures, the entry of which into the human body is possible without the phase of gastric digestion.

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

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

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

   In order to organize effective and high-quality therapeutic nutrition, which is part of the complex therapy of the patient, it is necessary to organize a Council for therapeutic nutrition in the institution. Despite the fact that it is an advisory body, its main tasks are to control the quality of therapeutic nutrition and the introduction of new therapeutic nutrition technologies. The Council for Clinical Nutrition not only approves the range of diets, specialized dietary products (composite protein powder mixtures), mixtures for enteral nutrition, dietary supplements to be introduced in this institution, but also conducts an internal examination of the usefulness and effectiveness of therapeutic nutrition. The Council also monitors the effectiveness of the introduction of new technologies for therapeutic nutrition.

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

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

   The process of organizing medical nutrition in medical institutions of our country must be considered from the standpoint of the current federal legislation. For the first time in the Russian legislation, the Federal Law of November 21, 2011 No. 323-FZ “On the Fundamentals of Protecting the Health of Citizens in the Russian Federation” defines the rules governing the basics of the organization of clinical nutrition.

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

   Organization of medical nutrition at the federal level

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

   Federal Law No. 323-FZ dated November 21, 2011 “On the Fundamentals of Protecting the Health of Citizens in the Russian Federation”. In accordance with Art. 76 of the Constitution of the Russian Federation, the law has direct effect on the territory of the entire country. In the field of health protection, this law introduces the most general, fundamental norms that require more detailed explanation in departmental orders, guidelines and information letters (see the text of the document on the website www..

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

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

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

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

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

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

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

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

   • indications for the use of enteral nutrition;
   • contraindications to the use of enteral nutrition;
   • assessment of malnutrition;
   • observation card of a patient receiving enteral nutrition (insert in the medical record of an inpatient, registration form 003/U);
   • methodology for determining the energy needs of the body;
   • the choice of the composition of mixtures for enteral nutrition;
   • requirements for basic nutrients (proteins, fats, carbohydrates) depending on the degree of malnutrition;
   • the need for protein in certain diseases;
   • ways of introducing enteral nutritional mixtures.

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

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

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

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

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

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

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

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

   Legal document	Nutritional norms
   Order of the Ministry of Health of Russia No. 330 of August 5, 2003 “On measures to improve clinical nutrition in medical institutions of the Russian Federation” (registered with the Ministry of Justice of Russia on September 12, 2003 No. 5073) as amended by orders of the Ministry of Health and Social Development of Russia of October 7, 2005 No. 624 (registered with the Ministry of Justice of Russia on November 1, 2020) 05 No. 7134), dated January 10, 2006 No. 2 (registered in the Ministry of Justice of the Russian Federation on January 24, 2006 No. 7411) and dated April 26, 2006 No. 316 (registered in the Ministry of Justice of Russia on May 26, 2006 No. 7878).	The average daily set of products per patient in medical institutions. Average daily food packages for children undergoing treatment in sanatorium-and-spa institutions of various profiles (except for tuberculosis). The average daily set of products for adults undergoing sanatorium treatment. Average daily food packages for children affected by radiation exposure, who are being treated in sanatoriums and resorts of various profiles (except for tuberculosis).
   Order of the Ministry of Health of the USSR No. 333 of March 10, 1986 “On Improving the Organization of Medical Nutrition in Maternity Hospitals (Departments) and Children's Hospitals (Departments)”. The text of the order has not been officially published. The specified nutritional norms for patients were agreed with the USSR Ministry of Finance (letter of the USSR Ministry of Finance dated September 12, 1985 No. 23-2-10/11).	Nutritional norm for patients in maternity hospitals (departments) and children's hospitals (departments) per patient per day in grams.
   Order of the Ministry of Health and Medical Industry of the Russian Federation of May 6, 1995 No. 122 “On measures to improve the operation of hospitals for war veterans”. The text of the order has not been officially published.	The average daily set of food products for patients undergoing treatment in hospitals (departments of general hospitals) for war veterans.
   Orders of the Ministry of Health of the USSR dated May 5, 1983 No. 530 “On approval of the instructions for accounting for food products in medical and preventive and other healthcare institutions financed by the state budget of the USSR” (as amended on May 17, 1984, December 30, 1987).	Unified food accounting system in a medical institution.

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

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

   The main document in this group is a card index of dietary dishes (see details about this document in the article “Specialized Card Index of Dietary Meals”, PD No. 1, or on the website www. calculate what the patient actually receives during the day, plan the work of the catering department, facilitate the implementation of organizational measures, calculate the consumption of products and the allocations allocated for them.

   Seven Day Consolidated Menu

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

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

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

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

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

   Layout card

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

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

   Diet nomenclature

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

   Special diets are assigned to a specific clinical and statistical group of patients, the condition of which requires the exclusion of certain foods from the therapeutic diet, are formed on the basis of standard diets in accordance with the nosological form of the disease, the phase of the disease. Protein correction of the diet is carried out with dry protein composite mixtures.

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

   Accounting and reporting documentation

   A number of documents that must be kept in a mandatory manner in a medical institution refer to accounting and reporting documents. In medical institutions, in order to optimize work, automated document management systems are being introduced that ensure the implementation of evidence-based principles of nutrition.

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

   The main legal document, on the basis of which food products are issued from the warehouse to the kitchen for cooking and appropriations for food are spent, is layout menu(form No. 44-MZ, order No. 330 dated 05.08.2003). The last digit in the layout menu is entered by the accounting officer, who calculates the total number of all products needed to prepare all the dishes for their release from the warehouse.

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

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

   If the number of patients changes compared to the menu layout data (or menu requirements) by more than three people, the dietary nurse prepares "Information on the movement of patients". In accordance with this document, it draws up in the form No. 434-fur (with an increase in the number of patients) "Demand for the warehouse" to receive additional products based on the main version of the standard diet. If the number of patients decreases compared to the previous day, then the products not used for cooking are returned to the warehouse in the same form with the indication “Return” (except for the products already put into the boiler when preparing breakfast).

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

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

   Cumulative statement reflects the actual consumption of all products for the past month. The accountant must prepare it by the 10th day of the next month and submit it to a dietitian or a person responsible for organizing clinical nutrition for analysis of the implementation of natural food norms. By the 15th day, a nutritionist or a person responsible for organizing therapeutic nutrition is obliged to inform the head doctor about the state of fulfillment of food standards and, if there are deficiencies, take measures to eliminate them.

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

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

   Each food service worker must have:

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

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

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

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

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

   The need for GOSTs

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

   Federal Law No. 184-FZ of December 27, 2002 "On Technical Regulation" the principles of standardization in the Russian Federation are defined, the rules for the application of technical regulations and national standards of the Russian Federation (GOST R 1.0-2004 "Standardization in the Russian Federation. Basic provisions") are established. This document states that technical regulations, i.e. federal laws that establish safety requirements, are mandatory for application to all products.

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

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

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   SanPiNs and resolutions

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

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

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

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

   “Technical regulation is a document 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 established by the legislation of the Russian Federation, or by a federal law, or by a decree of the President of the Russian Federation, or by a decree of the Government of the Russian Federation, or by a regulatory legal act of the federal executive body for technical regulation, and establishes mandatory for application and implementation requirements for objects of technical regulation (products or products and related requirements for products to design processes [including surveys], production, construction, installation, commissioning, operation, storage, transportation, sale and disposal)”.

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

   At the level of the subject of the Federation

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

   In accordance with Art. 39 of the Federal Law of the Russian Federation of November 21, 2011 No. 323-FZ “On the Fundamentals of Protecting the Health of Citizens in the Russian Federation” Order of the Government of the Russian Federation of October 25, 2010 No. 1873-r “On Approval of the Fundamentals of the State Policy of the Russian Federation in the field of healthy nutrition of the population for the period up to 2020” it is recommended that the executive authorities of the constituent entities of the Russian Federation take into account the provisions of the Fundamentals of the State Policy of the Russian Federation in the field of healthy nutrition of the population for the period up to 2020 when forming and implementing regional programs for socio-economic development.

   Decree of the President of the Russian Federation No. 598 dated May 7, 2012 “On Improving the State Policy in the Sphere of Healthcare” 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 of the population for the period up to 2020”.

   In order to fulfill the said regulatory legal acts established by the Government of the Russian Federation, as well as orders established by the Ministry of Health and Social Development of Russia, and in order to unify the requirements for the organization of dietary (therapeutic and preventive) nutrition, standardize the average daily food sets and the seven-day menu in medical organizations in Moscow, the Moscow Health Department issued Order No. methodological recommendations "Card file of dishes of dietary (therapeutic and preventive) nutrition of an optimized composition for children", which regulates the algorithm for organizing dietary (therapeutic and preventive) nutrition in medical organizations of the city.

   This order uses the norms of physical needs developed by Rospotrebnadzor (G. G. Onishchenko), the norms of protein correction of ready-made meals, calculated in accordance with the order of the Ministry of Health and Social Development of Russia No. 330. In accordance with the developments of the Federal State Budgetary Institution "Research Institute of Nutrition" of the Russian Academy of Medical Sciences, optimized average daily food sets are given. Thanks to the measures taken, the unification of requirements for the organization of dietary (therapeutic and preventive) nutrition, the standardization of average daily food sets and the seven-day menu in medical organizations in Moscow, heads of medical institutions can reasonably and efficiently spend financial resources. In addition, it became necessary to introduce non-departmental control over the expenditure of funds for medical nutrition and the quality of diet in medical institutions into the work of the Department of Health.

   In some constituent entities of the Russian Federation, documents have been developed for the implementation of the main directions of the Order of the Ministry of Health of Russia dated August 5, 2003 No. 330 “On measures to improve therapeutic nutrition in medical institutions of the Russian Federation” in accordance with the Procedure for providing medical care to the population in the profile “dietology” approved by the Ministry of Health and Social Development of Russia (see Table 3). The full texts of the documents presented in the table can be found on www..

   As an example of the introduction of standardization of the system of therapeutic and preventive nutrition, we can present an information letter of the Ministry of Health of the Territorial Fund of Compulsory Medical Insurance of the Saratov Region dated September 19, 2010 No. 1103-17 / 3146, No. 4529, addressed to the heads of government bodies and healthcare institutions. The document is presented in the form of guidelines "Standards for the organization of clinical nutrition" for catering for clinical and statistical groups of diseases. Clinical and statistical groups include nosological forms grouped into a set of clinical, laboratory and instrumental diagnostic signs that made it possible to identify diseases (poisoning, trauma, physiological state) belonging to a group of conditions with a common etiology and pathogenesis, clinical manifestations, 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:

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

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

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

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

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

   • technical support for the implementation of therapeutic diets;
   • food quality;
   • qualification of medical personnel involved in catering;
   • production, sales conditions, food quality;
   • accounting and reporting documentation used in the system of dietetics;
   • economic aspects of standardization, food procurement system, personalized accounting.

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

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

   At the level of a medical institution

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

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

   Diet meals are organized and carried out by a dietitian. The execution technology is associated with the appointment of a certain diet to the patient in accordance with the approved diet nomenclature. The organization of the catering department, the formation of nutritional therapeutic diets (diets) for various clinical and statistical groups of patients on the basis of standard diets and special and individual diets developed on their basis using food products in the preparation of meals, including dietary, specialized (composite protein powder mixtures) and baby food, is the basis for the formation of a therapeutic 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 the nutritional support team. In its absence, this task falls on doctors, as a rule, resuscitators, who specialize 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 for organizing and conducting enteral nutrition is regulated in Appendix No. 5 of the instructions for organizing enteral nutrition in medical institutions (approved by order of the Ministry of Health of Russia dated August 5, 2003 No. 330) (as amended on April 26, 2006). For enteral nutrition, enteral mixtures are used, which completely replace one or more meals, are used only for medical reasons when it is impossible to adequately meet the energy and plastic needs of the body in a natural way in a number of diseases. The extract of enteral mixtures from the food warehouse is carried out on the basis of Form No. 22-MZ "Information on individual and additional nutrition" after a preliminary calculation of the patient's need for the main ingredients, filling out an observation card for a patient receiving enteral nutrition (insert in the medical record of an inpatient, registration form No. 003/U).

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

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

   Enteral and parenteral nutrition are artificial types of nutrition that are used only for medical reasons when it is impossible to adequately meet the energy and plastic needs of the body naturally in a number of diseases and are presented in a number of reference manuals and recommendations for nutritional support in intensive care and resuscitation. These sections are not within the competence of a dietitian, they expand the possibilities of introducing nutrients into the patient's body using alternative methods (through the vascular bed) or specially created artificial balanced nutritional mixtures, the entry of which into the human body is possible without the phase of gastric digestion.

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

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

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

   In order to organize effective and high-quality therapeutic nutrition, which is part of the complex therapy of the patient, it is necessary to organize a Council for therapeutic nutrition in the institution. Despite the fact that it is an advisory body, its main tasks are to control the quality of therapeutic nutrition and the introduction of new therapeutic nutrition technologies. The Council for Clinical Nutrition not only approves the range of diets, specialized dietary products (composite protein powder mixtures), mixtures for enteral nutrition, dietary supplements to be introduced in this institution, but also conducts an internal examination of the usefulness and effectiveness of therapeutic nutrition. The Council also monitors the effectiveness of the introduction of new technologies for therapeutic nutrition.

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

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

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

   Application of specialized products

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

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

   Currently, in most medical institutions of the Russian Federation, the technology of protein correction of therapeutic diets has been introduced in order to increase the nutritional and biological value of diets. Dietitians quite often have one of the most difficult questions in the process of practical implementation of protein correction of therapeutic diets: what specialized food products can be used to include in dietary meals during protein correction? The answer to this question is quite simple: the selected product must comply with the requirements of GOST R 53861-2010, and it must have the appropriate certification and quality documents.

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

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

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

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

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

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

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