On the approval of the rules for organizing the provision of medical care to persons with chronic diseases, the frequency and timing of observation, the mandatory minimum and frequency of diagnostic tests

Order of the Minister of Healthcare of the Republic of Kazakhstan dated October 23, 2020 No. RK MH-149/2020. Registered with the Ministry of Justice of the Republic of Kazakhstan on October 26, 2020 No. 21513

Unofficial translation

In compliance with paragraph 3 of Article 88 of the Code of the Republic of Kazakhstan dated July 7, 2020 "On people's health and the health care system" ORDER:

1. To approve the Rules for organizing the provision of medical care to persons with chronic diseases of the frequency and timing of observation, the mandatory minimum and frequency of diagnostic tests in accordance with Appendix 1 to this order.

2. To recognize as invalid some orders of the Ministry of Health of the Republic of Kazakhstan in accordance with Appendix 2 to this order.

3. The Department of Medical Aid Organization of the Ministry of Health of the Republic of Kazakhstan, in accordance with the procedure established by the legislation of the Republic of Kazakhstan, shall ensure:

1) state registration of this order with the Ministry of Justice of the Republic of Kazakhstan;

2) posting this order on the Internet resource of the Ministry of Health of the Republic of Kazakhstan;

3) within ten working days after the state registration of this order with the Ministry of Justice of the Republic of Kazakhstan, submission to the Legal Department of the Ministry of Health of the Republic of Kazakhstan information on the implementation of the activities provided for in subparagraphs 1) and 2).

4. Control over the implementation of this order shall be entrusted to the supervising Vice-Minister of Health of the Republic of Kazakhstan.

5. This order shall be enforced upon the expiration of ten calendar days after the day of its first official publication.

The Minister of Healthcare
of the Republic of Kazakhstan	A. Tsoy

Appendix 1 to the order of the Minister of the Healthcare of the Republic of Kazakhstan October 23, 2020 No. RK MH-149/2020

Regulations for organizing the provision of medical care to persons with chronic diseases,
the frequency and timing of observation, the mandatory minimum and frequency of diagnostic tests

Chapter 1 General provisions

1. These Rules for organizing the provision of medical care to persons with chronic diseases, the frequency and timing of observation, the mandatory minimum and frequency of diagnostic tests (hereinafter referred to as the Rules) are developed in accordance with paragraph 3 of Article 88 of the Code of the Republic of Kazakhstan dated July 7, 2020 "On the health of the people and health care system" (hereinafter - the Code) and determine the procedure for organizing the provision of medical care to persons with chronic diseases.

2. Basic concepts used in these Rules:

1) profile specialist - a medical worker with a higher medical education who has a certificate in the field of health care;

2) the authorized body in the field of healthcare (hereinafter referred to as the authorized body) - the central executive body that carries out management and inter-sectoral coordination in the field of health protection of citizens of the Republic of Kazakhstan, medical and pharmaceutical science, medical and pharmaceutical education, sanitary and epidemiological well-being of the population, circulation of medicines and medical devices, the quality of medical services (assistance);

3) dynamic observation - systematic observation of the patient's health, as well as the provision of the necessary medical care based on the results of this observation;

4) clinical protocol - scientifically proven recommendations for the prevention, diagnosis, treatment, medical rehabilitation and palliative care for a specific disease or condition of the patient;

5) compulsory social health insurance (hereinafter referred to as the CSHI) - a set of legal, economic and organizational measures for the provision of medical care to consumers of medical services at the expense of the assets of the social health insurance fund;

6) the system of compulsory social health insurance - a set of rules and regulations established by the state, regulating relations between participants in the system of compulsory social health insurance;

7) guaranteed volume of free medical care (hereinafter referred to as the GVFMC) - the volume of medical care provided at the expense of budget funds.

Chapter 2. The procedure for organizing the provision of medical care to persons with chronic diseases,
the frequency and timing of observation, the mandatory minimum and frequency of diagnostic tests

3. Provision of medical care to persons with chronic diseases is carried out in the organizations of primary medical-sanitary and consultative-diagnostic care, depending on the place of attachment of the patient in accordance with the Rules for the provision of medical care approved by the authorized body in accordance with subparagraph 82) of Article 7 of the Code.

4. The provision of medical care to persons with chronic diseases is carried out in accordance with the standards in the field of health care approved by the authorized body in accordance with subparagraph 32) of Article 7 of the Code.

5. The provision of medical care to persons with chronic diseases is carried out through dynamic monitoring within the framework of the GVFMC and (or) in the CSHI system, in order to prevent complications, exacerbations of diseases, their prevention and medical rehabilitation of these persons.

6. Provision of medical care to persons with chronic diseases is carried out:

1) according to the list of diseases subject to dynamic observation in primary health care organizations (hereinafter - PHC) in accordance with the PHC rules approved by the authorized body in accordance with subparagraph 82) of Article 7 of the Code.

The frequency and timing of observation, the mandatory minimum and the frequency of diagnostic studies for chronic diseases subject to dynamic observation in PHC organizations within the GVFMC are determined in accordance with Appendix 1 to these Rules.

2) according to the list of diseases subject to dynamic observation at the level of consultative and diagnostic assistance (hereinafter - CDA), in accordance with the CDA Rules, approved by the authorized body in accordance with subparagraph 82) of Article 7 of the Code ...

The provision of medical care at the CDA level is carried out for socially significant diseases that are subject to dynamic observation by specialized specialists within the GVFMC and for chronic diseases that are subject to monitoring by specialized specialists within the GVFMC and (or) in the CSHI system.

The frequency and timing of observation, the mandatory minimum and the frequency of diagnostic studies for socially significant diseases subject to dynamic observation by specialized specialists within the GVFMC are determined in accordance with Appendix 2 to these Rules.

The frequency and timing of observation, the mandatory minimum and the frequency of diagnostic studies for chronic diseases subject to observation by specialized specialists within the GVFMC and (or) in the compulsory health insurance system are determined in accordance with Appendix 3 to these Rules.

7. Observation, including diagnostic studies, of persons with diseases not provided for in the Lists in accordance with Appendices 1, 2 and 3 to these Rules is carried out in accordance with the lists of medical care under the GVFMC and (or) in the CSHI system and clinical protocols.

8. The provision of medical care to persons with chronic diseases is carried out by specialists from PHC and CDA: PHC doctors (general practitioner, general practitioner / local pediatrician), paramedics (local nurse or paramedic) and specialized specialists in accordance with medical indications ... If indicated, social workers in the field of health care, psychologists and specialists from healthy lifestyle offices are involved.

9. When providing health care to people with chronic diseases, a PHC doctor will:

1) initial examination, collection, recording of complaints and anamnesis of the disease;

2) physical examination of the patient;

3) evaluation of the results of diagnostic studies;

4) assessment of the patient's self-help learning outcomes depending on the disease;

5) adjusting the individual plan of non-drug and drug treatment, the patient's self-control diary, taking into account the results of the examination, examination data, recommendations of specialized specialists, healthy lifestyle specialists;

6) referral to inpatient replacement and (or) inpatient treatment if signs of exacerbation and progression of the disease are detected, there are indications for medical supervision in inpatient conditions;

7) referral to medical rehabilitation in accordance with the standard for organizing the provision of medical rehabilitation to the population of the Republic of Kazakhstan, approved by the authorized body in accordance with subparagraph 32) of Article 7 of the Code, in the presence of a medical information system in electronic format;

8) issuance of recommendations for the preparation of documents for referral to medical and social expertise (hereinafter - MSE), in accordance with the Rules for conducting medical and social expertise, approved by the authorized body in the field of social protection of the population, in the presence of a medical information system in electronic format.

10. In the absence of complaints, signs of complications and progression of the disease based on the results of examination, deviations of laboratory and instrumental studies from the norm in patients with chronic diseases in accordance with Appendices 1, 2 and 3 to these Rules, the PHC doctor will correct the treatment, give recommendations for maintaining a healthy lifestyle life.

11. Within the time frame in accordance with Appendices 1, 2 and 3 to these Rules, a patient with a chronic disease is subject to examination by a specialized specialist.

12. The specialized specialist submits to the PHC doctor a medical report in the form (advisory and diagnostic opinion) approved by the authorized body in accordance with subparagraph 31) of Article 7 of the Code, which indicates the results of the examination and recommendations for further patient management, in the presence of a medical information system in electronic format ...

13. The PHC doctor, after receiving the advisory and diagnostic opinion, carries out further monitoring of the patient in accordance with the recommendations of the specialized specialist.

14. If indicated, the patient is referred for hospitalization in a round-the-clock or day hospital in accordance with the profile of the disease.

Inpatient care for persons with chronic diseases is provided in accordance with the Rules for the provision of inpatient care approved by the authorized body in accordance with subparagraph 82) of Article 7 of the Code.

Inpatient care is provided in accordance with the Rules for the provision of inpatient care, approved by the authorized body in accordance with subparagraph 82) of Article 7 of the Code.

15. A day or round-the-clock hospital doctor, upon discharge, draws up an extract from the inpatient's medical record in the form approved by the authorized body in accordance with subparagraph 31) of Article 7 of the Code, which indicates the volume of diagnostic tests, medical measures and recommendations for further observation and treatment. An electronic version of your statement will be sent to PHC at the place of attachment.

16. The PHC doctor, after receiving an extract from the inpatient's medical record, including in e-health systems, carries out further monitoring of the patient, taking into account the recommendations of a day or round-the-clock hospital doctor.

17.A person with a chronic disease is registered for follow-up at the PHC organization at the place of attachment on the basis of one of three documents:

1) PHC doctor's opinion;

2) an advisory opinion of a specialized specialist;

3) extracts from the medical card of an inpatient.

When registering a person taken for dynamic observation for the first time, the district nurse fills out insert 5 to the outpatient's medical card in the form approved by the authorized body in accordance with subparagraph 31) of Article 7 of the Code, including through information systems ...

In the absence of technical feasibility, it is issued in paper form, with subsequent entry into the information system.

18. Treatment implementation is monitored by a paramedical worker (hereinafter - SMA).

19. In case of repeated visits, the SMR interrogates persons, conducts a physical examination, sends them to laboratory and instrumental studies in accordance with Appendices 1, 2 and 3 to these Rules.

20. In the absence of complaints, signs of exacerbation and progression of the disease during physical examination, deviations of the results of laboratory and instrumental studies from the norm of CMP:

conducts a conversation and gives recommendations on maintaining a healthy lifestyle, if necessary, refers to specialists in healthy lifestyle;

explains to a patient with a high risk of developing complications or a life-threatening state of the rules of action for their development and the need for a timely call for an ambulance;

writes out prescriptions;

appoints the date of the next appearance by entering the date into the form approved by the authorized body in accordance with subparagraph 31) of Article 7 of the Code.

In the presence of complaints, signs of exacerbation, complications and progression of the disease based on the results of the examination, deviations in the results of laboratory and instrumental studies from the norm, the CMP sends the patient to the PHC doctor for an unscheduled examination ...

21. The PHC doctor and the head of the medical organization exercise control over the organization of work of the IDA on dynamic observation, including keeping records and entering data into the information system.

For people with chronic diseases, if indicated, PHC provides rehabilitative treatment and medical rehabilitation services, palliative care with the provision of special social and medical services.

22. Drug provision for persons with chronic diseases is carried out in accordance with subparagraph 6) of paragraph 1 of Article 108 of the Code.

23. For people with chronic diseases, dynamic observation is carried out within the framework of the disease management program (hereinafter - PMD).

24. With dynamic observation, specialists select patients for participation in PMD according to three nosologies: arterial hypertension, type 2 diabetes mellitus, chronic heart failure.

25. The criteria for selecting patients to participate in PMD are:

patients with primary arterial hypertension (uncomplicated);

patients with type 2 diabetes mellitus (compensated and subcompensated);

patients with chronic heart failure of NYHA classes II-IV with an ejection fraction of less than 40% or with an ejection fraction of more than 40% and left ventricular diastolic dysfunction according to echocardiography.

26. Patients with multiple conditions may be recruited to PMD if they meet the selection criteria set out in paragraph 25.

27. If the patient agrees to participate in PMD, the local nurse enters into an agreement in accordance with the Civil Code of the Republic of Kazakhstan.

The district nurse provides input of the electronic form of the contract on participation in PMD into the information system of e-health "Unified Payment System".

28. PMD monitoring of the patient is carried out by PHC specialists who hold the appropriate certificates of professional development. The PMDator within the PHC site is the community physician (general practitioner, community physician (pediatrician)).

29. For effective implementation of PMD in PHC organizations, it is recommended to create a multidisciplinary team consisting of PHC specialists, a psychologist, a healthy lifestyle specialist, a specialized specialist and other interested specialists.

30. In case of dynamic patient follow-up by PMD, the PHC and CMP physician by competence fills out a patient observation card participating in the PMD. The observation card contains information about the patient, the data of an objective examination, the results of laboratory and instrumental research methods.

31. The follow-up card is filled in at each patient visit to the PHC organization, followed by the introduction of updated CMP data into the PMD patient register.

32. Based on PMD patient registry data, PHC segmentation is performed on a regular basis by PHC. As a result of patient segmentation, the frequency of dynamic observation (examination by the SMR and PHC doctor), laboratory and instrumental studies, examinations by specialized specialists is determined.

33. The organization of the planned admission of patients is carried out by the CMP. Notification of patients participating in PMD is carried out in accordance with the list formed in the PMD patient register via telephone communication, SMS messages, social networks, mobile applications.

34. Notification (dialing) to patients is also carried out to invite for laboratory and instrumental studies to ensure follow-up of the patient.

35. Patient education on self-help is provided by PHC, tailored to the individual patient's level.

36. Within the framework of the PMD, the patient draws up an individual action plan for a short period (no more than 2 weeks), including the volume of physical activity, diet, lifestyle, elimination of bad habits.

37. Monitoring program performance is assessed based on the achievement of target indicators.

38. Deregistration of persons with chronic diseases is carried out according to the criteria and terms of observation in accordance with Appendices 1, 2 and 3 to these Rules.

39. The reasons for discontinuing follow-up of people with chronic diseases at PHC are:

1) change of attachment site (ensuring that the asset is transferred to PHC at the patient attachment site);

2) written refusal of the patient;

3) death of the patient.

Appendix 1 to the Rules medical care people with chronic diseases, frequency and timing of observation, mandatory minimum and multiplicity diagnostic research

List of diseases subject to dynamic monitoring in primary health care organizations within the guaranteed volume of free medical care

No.	Nosology ICD code	Inspection frequency			Minimum laboratory diagnostic tests		Terms of observation
		examination	Examination by the doctor PHC	examination by specialized specialists	Research	multiplicity
1	2	3	4	5	6	7	8
Infectious and parasitic diseases
1	Chronic viral hepatitis B (B18, including B18.0, B18.1. B18.2, B18.8), C and D, without liver cirrhosis	Once every 3 months	Once every 6 months	Once a year gastroenterologist and / or infectious disease specialist	complete blood count with platelets	Once every 6 months	for life with chronic viral hepatitis B, C (fibrosis stage F2) and D; deregistration after elimination of the virus in chronic viral hepatitis C (fibrosis stage less than F1)
					biochemical blood tests: alanine aminotransferase (ALaT), aspartate aminotransferase (ASaT), total bilirubin by fractions, creatinine, AFP	Once every 6 months
					coagulogram: international normalized ratio (INR)	Once every 6 months
					polymerase chain reaction for viral hepatitis B (HBV-DNA), qualitative with a positive result, PCR for viral hepatitis B (HBV-DNA) quantitative	Once every 6 months
					Liver ultrasound	Once a year
					indirect pulse elastometry (Fibroscan) of the liver	Once in two years
Diseases of the circulatory system
2	Arterial hypertension: 2.1. Essential (primary) hypertension, I10; 2.2. Hypertensive heart disease (hypertensive disease with predominant heart damage), I11; 2.3. Hypertensive (hypertensive) disease with predominant kidney damage, I12; 2.4. Hypertensive (hypertensive) disease with predominant damage to the heart and kidneys, I13; 2.5. Secondary hypertension, I15	Once every 3 months - for patients with medium and low risk, once a month - for patients with high and very high risk, and for those with low adherence to treatment	Every 6 months - for patients with medium and low risk, once every 3 months - for patients with high and very high risk, and for those with low adherence to treatment	Cardiologist once a year	general urine analysis	Once a year	for life
					biochemical blood test: determination of low density lipoproteins	Once a year
					electrocardiography	Once a year
					24-hour blood pressure monitoring (24 hours)	Once every 2 years
					echocardiography	Once every 2 years
3	Coronary heart disease: 3.1. Unstable angina pectoris, I20.0 **; 3.2. Other forms of angina pectoris, I20.8; 3.3. Chronic ischemic heart disease, I25	Once every 3 months	Once every 6 months	Cardiologist once a year	determination of low density lipoproteins	Once every 6 months	For life
					echocardiography	Once every 6 months
					Holter monitoring of the electrocardiogram (24 hours)	Once a year
					treadmill test	Once a year
		Once every 3 months	Once every 6 months	Cardiologist once a year	creatinine	Once a year	For life
					electrocardiogram	Once a year
					echocardiography	Once a year
	3.4. Heart failure, I 50;	Once every 3 months	Once every 3 months	monthly cardiologist	International normalized ratio (INR)	Once a week until the target is reached, then once a month;	For life
					blood chemistry: creatinine, alanine aminotransferase (ALaT), aspartate aminotransferase (ASaT), lactate dehydrogenase (LDH), free hemoglobin, total bilirubin, blood glucose, potassium, sodium	the first 3 months - monthly, then 1 time in 3 months;
					detailed general blood test with platelet count, duration of bleeding, blood clotting;	Once every 6 months
					natriuretic hormone, von Willebrand factor	Once every 6 months
					echocardiography	the first 3 months - monthly, then 1 time in 3 months;
					electrocardiography	Once every 3 months
					chest x-ray	Once a year
					esophagogastroduodenoscopy	Once a year
					ultrasound dopplerography of brachiocephalic vessels	Once a year
4	Extracranial diseases of the brachiocephalic arteries: 4.1. Cerebrovascular diseases, I65-I69 *** 4.2. Blockage and stenosis of the precerebral arteries, not leading to cerebral infarction, I65 4.3. Blockage and stenosis of cerebral arteries, not leading to cerebral infarction, I664.4. Other cerebrovascular diseases, I67 4.5. Vascular disorders of the brain in diseases classified elsewhere, I68 4.6. Consequences of cerebrovascular diseases, I69 4.7. Embolism and thrombosis of an artery of the upper extremities, I74.2 4.8. Aoritis in diseases classified elsewhere, I79.1	-	-	Once a year angiosurgeon, neurologist	ultrasound dopplerography of the brachiocephalic trunk	once every 6 months	For life
	4.9. Subarachnoid hemorrhage, I 60 Intracerebral hemorrhage, I 61 Other nontraumatic intracranial hemorrhage, I 62 Ischemic stroke, I 63 Stroke, unspecified as hemorrhage or infarction, I 64	once every 3 months	once every 6 months	Once a year	complete blood count with platelet count	once every 6 months	For life
					international normalized ratio (INR)	Once a year
					biochemical blood tests: lipid spectrum, blood glucose	once every 6 months
					Doppler ultrasound of brachiocephalic arteries in patients with stroke	once every 6 months
					electrocardiogram	According to indications for the correction of antihypertensive therapy
					echocardiography in patients with cardioembolic stroke	According to indications for the correction of antihypertensive therapy
					24-hour blood pressure monitoring (DBPM) in patients with intracerebral hemorrhage	According to indications for the correction of antihypertensive therapy
5	Valvular heart disease: 5.1. Chronic rheumatic heart disease, I05-I09 Rheumatic diseases of the mitral valve, I05 Rheumatic diseases of the aortic valve, I06 Rheumatic diseases of the tricuspid valve, I07 Multiple valve lesions, I08 Other rheumatic heart disease, I09 5.2. Non-rheumatic lesions of the heart valves, I34-I39 Non-rheumatic mitral valve disease, I34 Non-rheumatic aortic valve disease, I35 Non-rheumatic lesions of the tricuspid valve, I36 Pulmonary valve lesion, I37 Endocarditis, valve unspecified, I38 Endocarditis and valvular heart disease in diseases classified elsewhere, I39	once every 3 months	once every 6 months	once a year cardiologist	electrocardiography	once every 6 months	For life
					echocardiography	once a year
					Holter electrocardiography	once a year
6	Arrhythmias I47, Atrial fibrillation and flutter, I48	once every 3 months	once every 6 months. According to the indications, the frequency may increase	once a year cardiologist	electrocardiography	once every 6 months	For life
					Holter electrocardiography	once a year
					echocardiography	once a year
Diseases of the blood and blood-forming organs
7	Hereditary factor VIII deficiency (D66); Hereditary factor IX deficiency (D67) Von Willebrand disease (D68.0) Hereditary deficiency of other coagulation factors (D68.2)	once every 6 months	once every 6 months	once every 6 months gematologist	detailed complete blood count with platelet count, duration of bleeding, blood clotting	Twice a year	For life
Respiratory diseases
8	Chronic diseases of the lower respiratory tract: 8.1. Other chronic obstructive pulmonary disease, J44	once every 6 months (type A, B, mild, medium) once every 3 months (type C, D, severe and extremely severe)	once a year (type A, B, mild, moderate); once every 6 months (type C, D, severe and extremely severe)	once a year pulmonologist	spirography	once a year	for life
					pulse oximetry	once a year
					echocardiography	once a year
	8.2. Asthma, J45	a year once (light degree) once every 6 months (medium degree) once every 3 months (severe degree)	once a year (mild) once every 6 months (moderate to severe)	once a year pulmonologist	spirography	once every 6 months	for life
					echocardiography	once a year
Diseases of the digestive system
9	Diseases of the upper gastrointestinal tract: 9.1. Gastroesophageal reflux with esophagitis, K21.0 9.2. Ulcer of the stomach and duodenum, K25-K27 Stomach ulcer, K25 Duodenal ulcer, K26 Peptic ulcer, unspecified, K27 9.3. Chronic atrophic gastritis, K29.4 9.4. Polyps (polyposis) of stomach, K31.7	once every 3 months	once every 6 months	once a year gastroenterologist	esophagogastroduodenoscopy	once a year	deregistration in the absence of clinical and instrumental signs of the disease within 3 years
					histological examination of 1 block-preparation of surgical- biopsy material of the 3rd category of complexity	once a year
10	Non-infectious enteritis and colitis: 10.1. Crohn's disease (regional enteritis), K50 10.2. Ulcerative colitis, K51 10.3. Other noninfectious gastroenteritis and colitis, K52	once every 6 months	once a year	once a year gastroenterologist	esophagogastroduodenoscopy with histological examination of 1 block-preparation of surgical biopsy material, 3rd category of complexity	once a year	for life
					colonoscopy with histological examination of 1 block-preparation of surgical biopsy material, 3rd category of complexity	once a year
11	Liver cirrhosis, K70-K76 Toxic liver damage, K71 Hepatic failure, not elsewhere classified, K72 Chronic hepatitis, not elsewhere classified, K73 Fibrosis and cirrhosis of the liver, K74 Other inflammatory liver diseases, K75 Other liver diseases, K76	once every 3 months	once every 6 months	once a year gastroenterologist	complete blood count with platelets	once every 3 months	for life
					biochemical blood tests: determination of alanine aminotransferase (ALaT), determination of aspartate aminotransferase (ASaT), determination of bilirubin in serum, creatinine, albumin	once every 3 months
					international normalized ratio (INR)	once every 6 months
					Ultrasound of the liver and spleen	once every 6 months
					In cases of existing education up to 2 cm with the complexity of the diagnosis of HCC:
					Liver ultrasound	Once every 3-4 months
					determination of alpha-fetoprotein (AFP)	Once every 3-4 months
					indirect pulse hepatic elastometry	once a year
					esophagogastroduodenoscopy (in the absence of contraindications)	once every 6 months
Diseases of the musculoskeletal system and connective tissue
12	Arthropathies, dorsopathies: 12.1. Rheumatoid arthritis, M 05; M 06 12.2. Psoriatic arthropathies, M 07.3 12.3. Ankylosing spondylitis, M45 12.4. Juvenile (juvenile) arthritis, M08	once every 6 months	once a year	once a year rheumatologist, ophthalmologist	general blood analysis	once every 6 months	for life
					biochemical blood tests: determination of "C" reactive protein (CRP), blood creatinine, blood glucose (for patients taking glucorticosteroids), determination of alanine aminotransferase (ALaT), determination of aspartate aminotransferase (ASaT), determination of serum bilirubin (for patients taking cytostatics))	once every 6 months
					enzyme immunoassay for hepatitis B, C, HIV (for patients taking cytostatics and being on genetic engineering biological therapy)	once every 6 months
					X-ray of the affected segment	once a year
					X-ray of the pelvic bones (detection of aseptic necrosis of the femoral head)	once a year
					esophagogastroduodenoscopy (for patients taking glucorticosteroids and non-steroidal anti-inflammatory drugs)	once a year
13	Systemic lesions of connective tissue: 13.1. Polyarteritis nodosa, M30 13.2. Other necrotizing vasculopathies, M 31 13.3. Systemic lupus erythematosus, M32-M32.9 13.4. Dermatopolymyositis, M33-M33.9 13.5. Systemic sclerosis (systemic scleroderma), M.34-M34.9 13.6. Other systemic connective tissue lesions. M35	once every 3 months	Once every 6 months	once a year rheumatologist	blood creatinine	once every 6 months	for life
					general blood analysis	once every 6 months
					general urine analysis	once every 6 months
					determination of "C" reactive protein (CRP) semi-quantitative / qualitative in serum	once every 6 months
					blood glucose (for patients taking glucorticosteroids)	once every 6 months
					enzyme immunoassay for hepatitis B, C, HIV (for patients taking cytostatics and being on genetic engineering biological therapy)	once every 6 months
					plain chest x-ray twice a year(for patients taking cytostatics)	once every 6 months
					esophagogastroduodenoscopy (for patients taking glucorticosteroids and non-steroidal anti-inflammatory drugs)	once every 6 months
Endocrine system diseases, eating disorders and metabolic disorders
14	Diabetes mellitus type 1 in children E 10	in the first 3-6 months after the onset of diabetes - once a month, then - once every 3 months	in the first 3-6 months after the onset of diabetes - once a month, then - once every 3 months	in the first 3-6 months after the onset of diabetes - once a month, then - once every 3 months by an endocrinologist	determination of glycated hemoglobin in blood	once every 3 months	for life
					blood creatinine with the calculation of the glomerular filtration rate (GFR)	once a year
					wide pupil ophthalmoscopy	once a year
					electromyography	once a year
	Diabetes mellitus type 1 in adults E 10	once every 3 months	once every 6 months	once a year endocrinologist	biochemical blood tests: determination of glycated hemoglobin in the blood, blood creatinine with the calculation of the glomerular filtration rate (GFR), lipid spectrum	once every 3 months	for life
					wide pupil ophthalmoscopy	once a year
					electromyography	once a year
	Diabetes mellitus E11-E11.9	once every 3 months	once every 6 months	once a year with an endocrinologist	biochemical blood tests: determination of glycated hemoglobin in the blood, blood creatinine with the calculation of the glomerular filtration rate (GFR), lipid spectrum	once every 6 months	for life
					wide pupil ophthalmoscopy	once a year
15	Thyroid diseases: 15.1. Diffuse toxic goiter. Thyrotoxicosis, E05-E05.9 15.2. Hypothyroidism, E02	once every 6 months	once a year	once a year endocrinol	biochemical blood tests: determination of thyroid-stimulating hormone (TSH) in serum by immunochemiluminescence, determination of free triiodothyronine (T3) in serum by immunochemiluminescence, determination of free thyroxine (T4) in serum by immunochemiluminescence	once a year	for life
Diseases of the nervous system
16	Epilepsy, G 40	once every 6 months	once a year. According to the indications, the frequency may increase	once a year neurologist	electroencephalography	once a year	for life
17	Cerebral palsy, G 80	Once every 3 months	once every 6 months	once a year neurologist	GMFCS scale - determination of motor ability in children with cerebral palsy	once every 6 months	for life
					Bartel's daily life activity index.	once every 6 months
Diseases of the genitourinary system
18	Glomerular diseases: 18.1. Chronic nephritic syndrome, N03 18.2. Nephrotic syndrome, N04	once every 3 months	once every 6 months	once a year nephrologist	determination of protein in urine	once every 6 months	for life
					biochemical blood tests: determination of creatinine, urea, total protein, total cholesterol, serum glucose	once every 6 months
	Chronic renal failure (N18), End-stage renal disease (N18.0), Other manifestations of chronic renal failure (N18.8)	once every 6 months	once a year	twice a yearby a nephrologist	general blood test, general urine analysis (determination of protein in urine)	once every 3 months	for life
					Biochemical blood test: creatinine, urea, total protein, potassium, sodium, cholesterol, glucose	once every 6 months
					Kidney ultrasound	according to indications
19	Chronic interstitial nephritis, N11	once every 3 months	once every 6 months	once a year nephrologist	general clinical urine analysis (general urine analysis)	once a year	no relapse within 3 years
20	Hyperplasia of the prostate, N40	once every 3 months	once every 6 months	once a year urologist	determination of total prostate-specific antigen (PSA) in blood serum by immunochemiluminescence	once a year	no relapse within 3 years
21	Benign breast dysplasia, N60	once every 3 months	once every 6 months	once a year mammologist, gynecologist	mammography (4 images), ultrasound examination of the mammary glands	once a year	no relapse within 3 years
22	Non-inflammatory diseases of the female genital organs: 22.1. Endometriosis, N80 22.2. Polyp of female genital organs, N84 22.3. Glandular hyperplasia of endometrium, N85.0 22.4. Adenomatous endometrial hyperplasia, N85.1 22.5. Erosion and ectropion of cervix, N86 22.6. Leukoplakia of the cervix, N88.0	once every 3 months	once every 6 months	once a year gynecologist	taking a smear for oncocytology	once a year	1 year after treatment
	Benign neoplasm of the ovary, D27	once every 6 months	once a year	once a year gynecologist	pelvic ultrasound	once a year	no relapse within 3 years
Certain conditions arising in the perinatal period
23	Bronchopulmonary dysplasia arising in the perinatal period, P27.1	Once a month until the 1st year, then once every 6 months	with mild severity once every 6 months up to 1 year, then, if necessary, with moderate and severe severity from once every 3 months to 1 year, then up to 3 years once every 6 months then once a year	once a year pediatric pulmonologist	computed tomography of the chest and mediastinum	once a year	for life
					echocardiography	once a year
Congenital anomalies (malformations), deformities and chromosomal abnormalities (children)
24	Congenital heart defects in the postoperative period: 24.1. Congenital malformations of heart chambers and joints, Q20 24.2. Congenital malformations of cardiac septum, Q21 24.3. Congenital malformations of pulmonary and tricuspid valves, Q22 24.4. Congenital malformations (malformations) of aortic and mitral valves, Q23 24.5. Other congenital malformations of the heart, Q24 24.6. Congenital malformations of large arteries, Q25	Once a month	once every 3 months	once every 3 months pediatric cardiologist in the first year of follow-up, then according to indications	echocardiography	once every 3 months in the 1st year of observation, then once every 6 months	2 years, but with persisting pulmonary hypertension, residual shunt and valve insufficiency - for life
					electrocardiographic examination (in 12 leads)	once every 3 months in the 1st year of observation, then once every 6 months
25	Congenital malformations: 25.1. Congenital malformations of esophagus, Q39 25.2. Congenital diaphragmatic hernia, Q79 25.3. Anorectal malformations, Q42	within 1 to 6 months, once a month. Then up to a year once every 3 months. From the 2nd year of life 1 time in 6 months	once every 3 months during the 1st year of life; further from the 2nd year of life - once every 6 months	once a year pediatric surgeon	25.1. esophagogastroduodenoscopy for Q39	once a year	observation up to 3 years of age
					25.2. chest x-ray at Q79	once a year
					25.3. diagnostic calibration bougie of neoanus at Q42 (according to indications)	once a year

Appendix 2 to the Rules medical care people with chronic diseases, frequency and timing of observation, mandatory minimum and multiplicity diagnostic research

The list of socially significant diseases subject to dynamic observation by specialized specialists
at the level of consultative and diagnostic assistance within the guaranteed volume of free medical care

P / p No.	Name of diseases	Inspection frequency		Minimum laboratory and diagnostic tests		Terms of observation
		examination by a PHC doctor	examination by specialized specialists	research	multiplicity
1	Tuberculosis (A15 - A19)	once a year	examination by a phthisiatrician once every 6 months	Plain chest x-ray (1 projection)	once every 6 months	2 years
2	Human immunodeficiency virus (HIV) disease (B20-B24)	once a year	examination by an infectious disease specialist once every 6 months	Ultrasound of the hepatobiliopancreatic region, chest x-ray	once a year	for life
3	Malignant and benign neoplasms (C00-97; D00-09; D37-48, except for C81-96)	once a year	once a year oncologist	Complete blood count, general urine analysis	once a year	for life
				Biochemical blood test: total protein, creatinine, urea, uric acid, glucose, direct and total bilirubin, alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase	once a year
				Ultrasound of the abdominal organs, ultrasound of the pelvic organs (transabdominal), ultrasound of the prostate and urinary PMD with determination of residual urine	once a year
				Chest X-ray	once a year
				MRI of other organs	according to indications (once every 3 years)
				CT of other organs	according to indications (once every 3 years)
4	Malignant neoplasms of lymphoid, hematopoietic and related tissues (C81-96)	once a year	twice a yearoncologist, hematologist	Complete blood count with determination of the number of reticulocytes and morphological examination of erythrocytes	twice a year	for life
5	Myelodysplastic syndromes (D46) Chronic myeloproliferative disease (D47.1)	once a year	twice a yearoncologist, hematologist	Complete blood count with determination of the number of reticulocytes and morphological examination of erythrocytes	twice a year	for life
6	Hemolytic anemias (D 56; D 56.0-D 56.2; D 56.4; D 57; D 57.0-D 57.2)	once a year	twice a yearhematologist	Complete blood count with determination of the number of reticulocytes and morphological examination of erythrocytes	twice a year	for life
			once a year oncologist	General urine analysis
				Biochemical blood test: total bilirubin and its fractions, alanine aminotransferase, aspartate aminotransferase
7	Paroxysmal nocturnal hemoglobinuria (Markiafava-Mikeli) (D 59.5)	once a year	twice a yearhematologist	Complete blood count with determination of the number of reticulocytes and morphological examination of erythrocytes	twice a year	for life
			once a year oncologist	Biochemical blood test: bilirubin and its fractions, serum iron
				Study of osmotic resistance of erythrocytes, determination of the diameter and sphericity index of erythrocytes (Price-Jones curve)
				Hemoglobin electrophoresis	once a year
				Determination of the level of enzymes glucose-6 phosphate dehydrogenase, pyruvate kinase
				Coombs test
				Doppler ultrasound of the spleen and liver vessels
8	Aplastic anemia, unspecified (D 61.9)	once a year	twice a yearhematologist	Complete blood count with determination of the number of reticulocytes and morphological examination of erythrocytes	twice a year	for life
9	Idiopathic thrombocytopenic purpura (D 69.3)	once a year	twice a yearhematologist	Complete complete blood count with platelet count, duration of bleeding, blood clotting	twice a year	for life
10	Langerhans cell histiocytosis, not elsewhere classified (D 76.0)	once a year	once a year endocrinologist	General blood analysis; Blood chemistry;	Every 3-6 months	for life
				X-ray examination of bone lesions	Every 3 months
				Computed tomography of the lungs	Every 6 months
				Abdominal ultrasound	Every 6 months
11	Immunodeficiencies (D80-D84)	once a year	twice a yearhematologist	Complete complete blood count with platelet count, duration of bleeding, blood clotting	twice a year	for life
12	Diabetes mellitus (E10-E14)	once a year	once a year endocrinologist	biochemical blood tests: determination of glycated hemoglobin in the blood, blood creatinine with the calculation of the glomerular filtration rate (GFR), lipid spectrum	once every 3 months	for life
				wide pupil ophthalmoscopy	once a year
				electromyography	once a year
13	Other conditions of pituitary hyperfunction (E22.8)	once a year	once a year endocrinologist	X-ray of the skull (Turkish saddle)	once a year	follow-up for 2 years with stabilization of clinical parameters
			once a year gynecologist	MRI of the brain	according to indications (once every 2 years)
				Determination of prolactin	once a year
				Ultrasound of the pelvic organs, densitometry	once a year
14	Hypopituitarism (E23.0)	once a year	once a year endocrinologist	Skull X-ray (Turkish saddle)	once a year	for life
				MRI of the brain	according to indications (once every 2 years)
				Determination of adrenocorticotropic hormone (ACTH) in serum by ELISA method	once a year
15	Deficiency of other B vitamins (E 53.1)	once a year	once a year endocrinologist	Thyroid ultrasound	according to indications (once a year)	for life
				Complete blood count, general urine analysis	twice a year
16	Classical phenylketonuria (E 70.0)	once a year	once a year endocrinologist	Biochemical blood test: sodium, potassium, chlorides, creatinine and / or urea	1 time per year and according to indications	for life
				Complete blood count, general urine analysis	twice a year
17	Glycogen storage diseases (E 74.0)	once a year	once a year endocrinologist	Biochemical blood test: sodium, potassium, chlorides, creatinine and / or urea	according to indications (once a year)	for life
				Complete blood count, general urine analysis	twice a year
18	Other sphingolipidoses (E 75.2)	once a year	once a year endocrinologist	Biochemical blood test: sodium, potassium, chlorides, creatinine and / or urea	according to indications (once a year)	for life
				Complete blood count, general urine analysis	twice a year
19	Mucopolysaccharidosis (E 76.0-E 76.2)	once a year	once a year endocrinologist	Biochemical blood test: sodium, potassium, chlorides, creatinine and / or urea	according to indications (once a year)	for life
				Complete blood count, general urine analysis	twice a year
20	Porphyrias (E 80.2)	once a year	once a year endocrinologist	Biochemical blood test: sodium, potassium, chlorides, creatinine and / or urea	according to indications (once a year)	for life
				Complete blood count, general urine analysis	twice a year
21	Copper metabolism disorders (E 83.0)	once a year	once a year endocrinologist	Biochemical blood test: sodium, potassium, chlorides, creatinine and / or urea	according to indications (once a year)	for life
				Complete blood count, general urine analysis	twice a year
22	Cystic fibrosis with other manifestations (E 84.8)	once a year	once a year endocrinologist	Biochemical blood test: sodium, potassium, chlorides, creatinine and / or urea	according to indications (once a year)	for life
				Complete blood count, general urine analysis	twice a year
23	Hereditary familial amyloidosis without neuropathy (E 85.0)	once a year	once a year endocrinologist	Biochemical blood test: sodium, potassium, chlorides, creatinine and / or urea	according to indications (once a year)	for life
				Complete blood count, general urine analysis	twice a year
				Kidney ultrasound	once a year
24	Plasma protein metabolism disorders (E 88.0)	once a year	once a year endocrinologist	Biochemical blood test: sodium, potassium, chlorides, creatinine and / or urea	according to indications (once a year)	for life
				Complete blood count, general urine analysis	twice a year
				Kidney ultrasound	once a year
25	Mental and Conduct Disorders (F00-F99)	once a year	once every 6 months psychiatrist	Electroencephalography, psychocorrective conversation for the purpose of social and labor adaptation	once a year	2 years after the permanent compensation
26	Motor neuron disease (G 12.2)	once a year	once a year neurologist	General blood analysis; general urine analysis; biochemical blood test: blood electrolytes, determination of urea, residual nitrogen, creatinine; electrocardiography, electroneuromyography	twice a year	for life
27	Degenerative diseases of the nervous system (G30-G32)	once a year	once a year neurologist	Electrocardiography; general blood analysis; general urine analysis; biochemical blood test: cholesterol, high density lipoproteins, low density lipoproteins, blood glucose; coagulogram	once a year	for life
			Psychiatrist 2 times a year	Electroencephalography, USDG of cerebral vessels	once a year
28	Demyelinating diseases of the central nervous system (G35-G37)	once a year	twice a yearneurologist	Electrocardiography, general blood test, general urinalysis, biochemical blood test: cholesterol, high density lipoproteins, low density lipoproteins, blood glucose; electroencephalography; electroneuromyography	once a year	for life
				MRI of the brain	according to indications (once every 2 years)
29	Other types of generalized epilepsy and epileptic syndromes (G 40.4)	Once a month	once every 3 months neurologist; once every 6 months ophthalmologist	Complete blood count	4 times a year	clinical and neurophysiological remission within 5 years. Social adaptation
				General urine analysis	4 times a year
				Biochemical blood test (liver and kidney tests, electrolytes)	4 times a year
				Echocardiography	once a year
				Electrocardiography	once a year
				Kidney ultrasound	2 times a year
				Abdominal ultrasound	2 times a year
				CT scan of the brain	once a year
				MRI of the brain	once a year
30	Encephalopathy, unspecified (G 93.4)	Once a month	once every 3 months neurologist; once every 6 months ophthalmologist	Echocardiography	once a year	clinical and neurophysiological remission within 5 years. social adaptation
				Electrocardiography	once a year
				Kidney ultrasound	2 times a year
				Abdominal ultrasound	2 times a year
				CT scan of the brain	once a year
				MRI of the brain	once a year
31	Acute rheumatic fever (I00-I02)	twice a year	twice a year rheumatologist, once a year cardiac surgeon, once a year otorhinolaryngologist, once a year dentist, once a year neurologist	General blood analysis,	twice a year	for life
				General urine analysis	once a year
				Creatinine, ALT, AST, fibrinogen, Antistreptolysin "O", C-reactive protein	twice a year
				Electrocardiographic examination (in 12 leads)	twice a year
				Echocardiography	twice a yearduring the first year, then once a year
				Chest X-ray	once a year
				X-ray of joints	according to indications
32	Primary pulmonary hypertension (I 27.0)	once every 6 months	twice a year cardiologist	Complete blood count, general urine analysis	once a year	for life
				Electrocardiographic examination (in 12 leads)	twice a year
				Echocardiography	once a year
				Biochemical blood test: total serum cholesterol, high density lipoproteins, low density lipoproteins, TAG, potassium	once a year
				Coagulogram: determination of prothrombin time (PT) followed by calculation of prothrombin index (PTI) and international normalized ratio (INR) in blood plasma by manual method (PT-PTI-INR)	once a year
33	Other interstitial pulmonary diseases (J 84; J 84.0; J 84.1; J 84.8; J 84.9)	twice a year	Pulmonologist 2 times a year	Complete blood count, urinalysis, chest x-ray, spirometry	once a year	for life
34	Bullous disorders (L 10; L 13.0)	once a year	once a year dermatologist	General blood analysis	once a year	for life
35	Osteogenesis incomplete (Q 78.0)	once a year	once a year traumatologist-orthopedist	Determination of rheumatoid factor in blood serum quantitatively on the analyzer	once a year	restoration of functional range of motion in the joint
				Radiography of one segment
36	Congenital ichthyosis (Q 80)	once a year		General blood test, general urine analysis, biochemical blood test	once a year	for life
37	Epidermolysis bullosa (Q 81)	once a year		General blood test, general urine analysis, biochemical blood test	once a year	for life

Appendix 3 to the Rules medical care people with chronic diseases, frequency and timing of observation, mandatory minimum and multiplicity diagnostic research

The list of chronic diseases subject to observation by specialized specialists at the level of consultative and
\diagnostic assistance within the guaranteed volume of free medical care and (or) in the system of compulsory social health insurance

P / p No.	Name of a group of diseases	Inspection frequency		Minimum laboratory and diagnostic tests		Terms of observation
		examination by a PHC doctor	examination by specialized specialists	research	multiplicity
Consequences of transferred infectious and parasitic diseases
1	Consequences of previous polio (B91)	twice a year	twice a year neurologist	Electroneuromyography, fundus examination	twice a year	for life
2	Condition after surgery for echinococosis (B67)	twice a year	twice a year surgeon	Ultrasound of the abdominal organs	once a year	for life
				Ultrasound of the pleura and pleural cavity
				Chest X-ray (2 projections)
3	Consequences of postponed tuberculosis (B90)	once a year	once a year phthisiatrician	Chest X-ray (2 projections)	twice a year	for life
				Tuberculin diagnostics (for children)
Diseases of the blood and blood-forming organs
4	Iron deficiency anemia (D50)	once every 6 months	twice a year hematologist	Complete blood count with determination of the number of reticulocytes and morphological examination of erythrocytes	twice a year	before normalization of indicators
5	Other hereditary hemolytic anemias (D58)	once every 6 months	twice a year hematologist	Complete blood count with determination of the number of reticulocytes and morphological examination of erythrocytes	twice a year	for life
			once a year - oncologist	General urine analysis
				Biochemical blood test: total bilirubin and its fractions, alanine aminotransferase, aspartate aminotransferase
6	Acquired hemolytic anemia (D59 except D59.5)	once every 6 months	twice a year hematologist	Complete blood count with determination of the number of reticulocytes and morphological examination of erythrocytes	twice a year	for life
			once a year - oncologist	Biochemical blood test: bilirubin and its fractions, serum iron
				Study of osmotic resistance of erythrocytes, determination of the diameter and sphericity index of erythrocytes (Price-Jones curve)
				Hemoglobin electrophoresis
				Determination of the level of enzymes glucose-6 phosphate dehydrogenase, pyruvate kinase	once a year
				Coombs test
				Doppler ultrasound of the spleen and liver vessels
7	Acquired pure red cell aplasia (erythroblastopenia) (D60), other aplastic anemias (D61, except D 61.9), Acute post-hemorrhagic anemia (D62), Anemia in neoplasms (D63)	once every 6 months	twice a year hematologist	Complete complete blood count with platelet count, duration of bleeding, blood clotting	twice a year	for life
			once a year oncologist	Biochemical blood test: determination of creatinine in patients on immunosuppressive therapy, bilirubin and its fractions, alanine aminotransferase, aspartate aminotransferase	once a year
Endocrine system diseases, eating disorders and metabolic disorders
8	Other forms of hypothyroidism (E03), Other forms of non-toxic goiter (Nodular and mixed euthyroid goiter after surgery) (E04)	once a year	once a year endocrinologist	Determination of thyroid stimulating hormone (TSH), free thyroxine (T4), antibodies to thyroid peroxidase in blood serum by enzyme immunoassay	once a year	for life
				General blood analysis	once a year
				Ultrasound of the thyroid gland, electrocardiography	once a year
				X-ray of knee joints and feet, as well as hands for determining bone age in children under 15 years of age	according to indications (once every 2 years)
9	Hypoparathyroidism (E20)	once a year	once a year endocrinologist	Parathyroid hormone by enzyme immunoassay	once a year	for life
				Biochemical blood test: phosphorus, total and ionized calcium, glucose, creatinine	once a year
10	Pituitary hyperfunction (E22, except E 22.8)	once a year	once a year endocrinologist	Skull X-ray (Turkish saddle)	once a year	follow-up for 2 years with stabilization of clinical parameters
			once a year gynecologist	MRI of the brain	according to indications (once every 2 years)
				Determination of prolactin	once a year
				Ultrasound of the pelvic organs, densitometry	once a year
11	Hypofunction and other disorders of the pituitary gland (E 23, except for E 23.0) Diabetes insipidus (E23.2)	once a year	once a year endocrinologist	Skull X-ray (Turkish saddle)	once a year	for life
				MRI of the brain	according to indications (once every 2 years)
				Determination of adrenocorticotropic hormone (ACTH) in serum by ELISA method	once a year
12	Itsenko-Cushing's syndrome (E24)	once a year	once a year endocrinologist	Ultrasound of the adrenal glands	once a year	for life
				Determination of blood cortisol
				Determination of the level of free cortisol in daily urine
				Determination of fasting blood glucose and 2 hours after eating
				X-ray of the thoracic and lumbar spine, determination of visual fields
13	Adrenogenital disorders (E25)	once a year	once a year endocrinologist, urologist	Determination of potassium (K) in serum	once a year	follow-up for 5 years with stable remission
				Determination of sodium (Na) in serum	once a year
				Left hand radiography	once a year
				Determination of testosterone levels	once a year
				Determination of thyroid stimulating hormone (TSH), free thyroxine (T4), antibodies to thyroid peroxidase in blood serum by enzyme immunoassay	once a year
				Ultrasound of the adrenal glands	according to indications (once a year)
				Ultrasound of the pelvic organs	according to indications (once a year) in adolescent girls
				Testicular ultrasound	according to indications (once a year) in boys
14	Ovarian dysfunction (E28)	once a year	once a year gynecologist, endocrinologist	Complete blood count, general urine analysis	once a year	follow-up for 3 years with stable remission, improvement of clinical parameters
				Hand radiography	once a year
				Determination in blood serum by enzyme immunoassay: thyroid stimulating hormone (TSH), follicle-stimulating hormone (FSH), luteinizing hormone (LH), prolactin, total T, DEAS, progesterone, cortisol, determination of globulin-binding sex hormone (SHBG)	once a year
				Ultrasound of the pelvic organs	once a year
				Breast ultrasound	once a year
				Thyroid ultrasound	once a year
15	Puberty disorders, not elsewhere classified (E30)	once a year	once a year gynecologist, endocrinologist	Complete blood count, general urine analysis	once a year	follow-up for 3 years with stable remission, improvement of clinical parameters
				Determination in blood serum by enzyme-linked immunosorbent assay: thyroid stimulating hormone (TSH), follicle-stimulating hormone (FSH), luteinizing hormone (LH), prolactin, total T, DEAS, progesterone, cortisol, determination of globulin-binding sex hormone (SHBG)
				Ultrasound of the pelvic organs
				Breast ultrasound
				Thyroid ultrasound
16	Other endocrine disorders (E34)	once a year	once a year endocrinologist	Biochemical blood test: sodium, potassium, chlorides, creatinine and / or urea	according to indications (once a year)	for life
				Complete blood count, general urine analysis	twice a year
				Ultrasound of the pelvic organs	twice a year
				Determination of follicle-stimulating hormone, luteinizing hormone (LTH), estrogen, pregnandiol, androgen, 17 KS	twice a year
17	Vitamin D deficiency (E55)	once a year	Once a year orthopedic surgeon	Biochemical blood test for calcium and phosphorus	twice a year	for three years
				Radiography of the wrist joint	according to indications (once a year)
Diseases of the genitourinary system
18	Female genital prolapse (N81)	once a year	once a year obstetrician-gynecologist	Oncocytology smear	once a year	until complete recovery
				Ultrasound of the pelvic organs
19	Lack of menses, scanty and infrequent menses (N91)	once a year	once a year obstetrician-gynecologist	General blood analysis	once a year	restoration of menstrual function
				Blood test for hormones by enzyme immunoassay: progesterone, follicle-stimulating hormone (FSH), luteinizing hormone (LH), testosterone, thyroid-stimulating hormone (TSH), free T3, antibodies to thyroid peroxidase in serum
				Ultrasound of the pelvic organs (transvaginal)
20	Other abnormal bleeding from the uterus and vagina (N93)	once a year	once a year obstetrician-gynecologist	Blood test for hormones by enzyme immunoassay: progesterone, follicle-stimulating hormone (FSH), luteinizing hormone (LH), testosterone, thyroid-stimulating hormone (TSH), free T3, antibodies to thyroid peroxidase in serum by enzyme-linked immunosorbent assay	once a year	restoration of menstrual function
				Ultrasound of the pelvic organs (transvaginal)
				Coagulogram: PT, fibrinogen, APTT, INR
				Hysteroscopy
21	Female infertility (N97)	once a year	once a year obstetrician-gynecologist	Oncocytology smear; cleanliness smear	once a year	restoration of fertility
				Ultrasound of the pelvic organs
				Complete blood count, blood test for hormones by enzyme immunoassay: progesterone; follicle-stimulating hormone (FSH), luteinizing hormone (LH), testosterone, thyroid stimulating hormone (TSH), free T3, antibodies to thyroid peroxidase in serum
Diseases of the nervous system
22	Consequences of inflammatory diseases of the central nervous system (G09)	once every 6 months	Twice a year, a neurologist and an ophthalmologist	Fundus examination	twice a year	observation until complete or partial recovery of functions is achieved
				MRI of the brain	according to indications (once every 2 years)
23	Parkinson's disease (G20)	once a year	twice a year neurologist	Electrocardiography	once a year	for life
				Doppler ultrasonography of cerebral vessels	once a year
				MRI of the brain	according to indications (once every 2 years)
24	Other degenerative diseases of the basal ganglia (G23)	once a year	twice a year neurologist	Electrocardiography	once a year	for life
				Doppler ultrasonography of cerebral vessels	once a year
				MRI of the brain	according to indications (once every 2 years)
25	Migraine (G43)	once a year	twice a year neurologist	Echocardiography	once a year	observation until full or partial recovery of functions: improving the quality of life
				Echoencephalography	according to indications (once a year)
				X-ray of the sinuses	according to indications (once a year)
				Ultrasound of the brain in children under 1 year of age	according to indications (once a year)
				Electroencephalography, video monitoring, USDG of brachiocephalic vessels	according to indications (once a year)
26	Lesions of the trigeminal nerve (G50)	once a year	once a year neurologist	MRI of the brain	according to indications (once every 2 years)	follow-up for 1 year, subject to regression and / or stabilization of neurological symptoms
27	Facial nerve disorder (G51)	once a year	once a year neurologist	Electroneuromyography	once a year	follow-up for 1 year, subject to regression and / or stabilization of neurological symptoms
28	Other cranial nerve disorders (G52)	once a year	once a year neurologist	Electroneuromyography	once a year	follow-up for 1 year, subject to regression and / or stabilization of neurological symptoms
				MRI of the brain	according to indications (once every 2 years)
29	Nerve root and plexus disorders (G54)	once a year	once a year neurologist	Electroneuromyography	once a year	follow-up for 1 year, subject to regression and / or stabilization of neurological symptoms
				MRI of the brain	Once every 2 years
30	Myasthenia gravis and other neuromuscular synapse disorders (G70.0-G70.9)	twice a year	twice a year neurologist	Electroneuromyography	twice a year	for life
				CT scan of the chest, MRI of the mediastinal organs	according to indications (once a year)
31	Other diseases of the spinal cord (G95)	once a year	twice a year neurologist	Electrocardiography, blood electrolytes	twice a year	for life
				Electroneuromyography	once a year
				MRI of the cervicothoracic spine	according to indications (once every 2 years)
Eye diseases
32	Iridocyclitis (H20)	once a year	once a year ophthalmologist	Skioscopy	once a year	relief of the inflammatory process
				Tonometry	once a year
				Biomicroscopy	once a year
33	Chorioretinal dystrophies (after laser surgery) (H32)	once a year	once a year ophthalmologist	Visometry	once a year	for life
				Perimetry, ophthalmoscopy, eye biomicroscopy	once a year
34	Retinal detachment and tears (H33)	once a year	once a year ophthalmologist	Visometry	once a year	for life
				Perimetry, ophthalmoscopy, eye biomicroscopy	once a year
				OST, cycloscopy	once a year
				Eyeball ultrasound	according to indications (once every 2 years)
			once a year neurologist	USDG of the brachiocephalic trunk	according to indications (once every 2 years)
35	Retinal vascular occlusion (H34)	once a year	once a year ophthalmologist	Visometry	once a year	for life
				Perimetry, ophthalmoscopy, eye biomicroscopy	once a year
			once a year neurologist	OST, cycloscopy	once a year
				USDG of the brachiocephalic trunk	according to indications (once every 2 years)
36	Other diseases of the retina (H35)	once a year	once a year ophthalmologist	Visometry	once a year	for life
			once a year neurologist	Perimetry, ophthalmoscopy, eye biomicroscopy
37	Diseases of the eyeball (H44)	once a year	once a year ophthalmologist	Visometry	once a year	for life
				Perimetry	once a year
38	Glaucoma (H40)	once a year	once a year ophthalmologist	Daily tonometry (non-contact) (1 eye)	once a year	for life
				Unloading and stress tests for glaucoma (1 eye)
				Perimetry
				Keratometry
				Gonioscopy
39	Refractive and accommodation disorders (H52)	once a year	once a year ophthalmologist	Refractometry, skiascopy	once a year	improvement of visual acuity
				Visometry
				Ophthalmoscopy
40	Visual disturbance (H53)	once a year	Ophthalmologist twice a year	Refractometry, skiascopy, visometry, ophthalmoscopy	once a year	improvement of visual acuity
Diseases of the hearing organs
41	Suppurative otitis media (H66)	once a year	once a year otorhinolaryngologist	X-ray of the temporal bone pyramid	once a year	relief of the inflammatory process
42	Other diseases of the middle ear and mastoid (H74)	once a year	once a year otorhinolaryngologist	X-ray of the temporal bone pyramid	once a year	relief of the inflammatory process
43	Conductive and sensorineural hearing loss (H90)	once a year	once a year otorhinolaryngologist	Tonal threshold audiometry	once a year	for life
Diseases of the circulatory system
44	Cardiomyopathy (I42)	once every 6 months	twice a yearcardiologist	Complete blood count, general urine analysis	once a year	for life
				Electrocardiographic examination (in 12 leads)	twice a year
				Echocardiography	once a year
				Biochemical blood test: total serum cholesterol, high density lipoproteins, low density lipoproteins, TAG, potassium	once a year
				Coagulogram: determination of prothrombin time (PT) followed by calculation of prothrombin index (PTI) and international normalized ratio (INR) in blood plasma by manual method (PT-PTI-INR)	once a year
45 ...	Atrioventricular (atrioventricular) block and left bundle branch block (I44)	once every 6 months	twice a yearcardiologist	General blood analysis	once a year	until complete recovery and no relapse within 5 years
				Electrocardiographic examination (in 12 leads)	twice a year
				Echocardiography	once a year
				Biochemical blood test: low density lipoproteins, potassium	once a year
46	Atrioventricular (atrioventricular) block and right bundle branch block (I45)	once every 6 months	twice a yearcardiologist	Determination of sodium (Na) in serum	once a year	for life
				Coagulogram: determination of prothrombin time (PT) followed by calculation of prothrombin index (PTI) and international normalized ratio (INR) in blood plasma by manual method (PT-PTI-INR)	once a year
47	Hereditary and idiopathic neuropathy (G60)	once a year	once a year neurologist	General blood analysis; general urine analysis; coagulogram; prothrombin index, INR; biochemical blood test: blood glucose, cholesterol, low and high density lipoproteins	once a year	for life
			once a year cardiologist	Electrocardiography, USDG of cerebral vessels, USDG of brachiocephalic arteries	once a year
				MRI of the brain	according to indications (once every 2 years)
48	Capillary diseases (I78)	once a year	once a year hematologist, rheumatologist, angiosurgeon (if indicated)	General blood analysis	once a year	until complete recovery and no relapse within 5 years
				General urine analysis	once a year
				Biochemical blood test: total and direct bilirubin	once a year
49	Atherosclerosis (I70)	once a year	once a year surgeon, angiosurgeon, cardiologist	Blood chemistry; cholesterol, HDL, LDL, TAG, glucose	once a year	for life
				Doppler ultrasonography of the arteries of the upper and lower extremities
				Doppler ultrasound of the branches of the aortic arch
50	Aneurysm and aortic dissection (I71)	twice a year	Angiosurgeon 2 times a year	USDG of the abdominal aorta and its branches	once a year	for life
				CT with contrast enhancement of the aorta	according to indications (once every 2 years)
51	Other peripheral vascular diseases (I73)	once a year	once a year surgeon, angiosurgeon	Determination of rheumatoid factor in blood serum quantitatively on the analyzer	once a year	follow-up for 3 years in the absence of signs of disease progression
				Doppler ultrasonography of the arteries of the upper and lower extremities	once a year
52	Other disorders of arteries and arterioles (I77)	once a year	once a year surgeon, angiosurgeon	General blood analysis	once a year	observation for 1 year in the absence of signs of disease progression
				Doppler ultrasonography of the arteries of the upper and lower extremities
53	Phlebitis and thrombophlebitis (I80) Postphlebitic syndrome (I87) Varicose veins of the lower extremities (I83)	once a year	once a year surgeon, angiosurgeon	Doppler ultrasonography of the veins of the lower extremities	once a year	follow-up for 2 years in the absence of signs of disease progression
Respiratory diseases
54	Emphysema of lung (J43.9)	once a year	once a year surgeon, pulmonologist	Chest x-ray, spirometry	twice a year	for life
				CT scan of the chest	once a year
Diseases of the digestive system
55	Gingivitis and periodontal disease (K05)	once a year	once a year dentist	General blood analysis	once a year	observation for 1 year
				Jaw X-ray (2 projections)
56	Other diseases of the esophagus (K22)	once a year	once a year gastroenterologist	Videoesophagogastroduodenoscopy	once a year	observation until stable remission is achieved
57	Hernia of the anterior abdominal wall (K40-43.9): Inguinal hernia (K40) Femoral hernia (K41) Umbilical hernia (K42) Incisional ventral hernia (K43.9)	once a year	twice a year surgeon	Ultrasound of the anterior abdominal wall, spirography	twice a year	observation until the hernia is removed
58	Diverticular bowel disease (K57)	once a year	twice a year surgeon	Videoesophagogastroduodenoscopy, abdominal ultrasound	twice a year	for life
59	Fissure and fistula of anal and rectal region (K60)	once a year	twice a year surgeon	Rectomanoscopy	twice a year	observation if the crack does not go away for more than two months surgical treatment is indicated
60	Cholelithiasis (K80) Chronic cholecystitis (K81)	once a year	once a year gastroenterologist, surgeon	Biochemical blood test: total and direct bilirubin	once a year	observation until removal of the bile PMD lesion, achieving stable remission
				Ultrasound of the abdominal organs	once a year
Diseases of the skin, subcutaneous tissue
61	Atopic dermatitis (L20)	once a year	once a year dermatologist	General urine analysis	once a year	follow-up for 5 years with complete recovery and no relapse
				Biochemical blood test: total and direct bilirubin, glucose	once a year
62	Psoriasis (L40)	once a year	once a year dermatologist	General blood analysis	twice a year	follow-up for 5 years with complete recovery and no relapse
				General urine analysis	twice a year
				Biochemical blood test: determination of alanine aminotransferase (ALaT), aspartate aminotransferase (ASaT), total and direct bilirubin, glucose	once a year
63	Erythema multiforme (L51)	once a year	once a year dermatologist	General blood analysis	once a year	follow-up for 5 years with complete recovery and no relapse
				General urine analysis	once a year
				Biochemical blood test: total and direct bilirubin, glucose	once a year
64	Granulomatous changes of skin and subcutaneous tissue (L92)	once a year	once a year dermatologist	General blood analysis	twice a year	follow-up for 5 years with complete recovery and no relapse
				General urine analysis	twice a year
				Biochemical blood test: aspartate aminotransferase, total bilirubin and its fractions, glucose	once a year
65	Lupus erythematosus (L93)	once a year	once a year dermatologist	General blood analysis	once a year	for life
				General urine analysis	once a year
				Determination of glucose in urine (quantitative)	once a year
66	Other diseases of the skin and subcutaneous tissue, not elsewhere classified (L98)	once a year	once a year dermatologist	Biochemical blood test: total bilirubin and its fractions, glucose	once a year	for life
67	Optional and obligate skin precancers; cutaneous horn, cysts, radiation dermatitis, xeroderma pigmentosa, Paget's disease, Bowen's disease, (L85.8, L72.9, L58, Q82.1, M88, L90, L91)	once a year	once a year dermatologist	General blood analysis	once a year	follow-up for 5 years with complete recovery and no relapse
Diseases of the musculoskeletal system
68	Arthrosis (M15-M19)	once a year	Traumatologist-orthopedist twice a year	Determination of antistreptolysin "O" in blood serum quantitatively on the analyzer	once a year	reduction of pain syndrome, signs of inflammation
				Determination of rheumatoid factor in blood serum quantitatively on the analyzer	once a year
				X-ray of the hip joints	once a year
				X-ray of the knee joints	once a year
69	The consequences of trauma - contracture, ankylosis in a vicious position, osteomyelitis in adults (M21)	once a year	once a year traumatologist-orthopedist	X-ray of the affected segment	once a year	improvement of functional range of motion in joints
				Determination of rheumatoid factor in blood serum quantitatively on the analyzer	once a year
70	Osteopathy and chondropathy (M80-M94)	once a year	Traumatologist-orthopedist twice a year	General blood analysis	Twice per year	observation for 3 years in the absence of exacerbation
				Determination of total blood protein	once a year
				Radiography of one segment
				Fistulography
Lesions in the perinatal period
71	Subdural hemorrhage due to birth injury (P10.0)	twice a year	twice a yearneurologist	Electroencephalography	Twice a year	observation until complete or partial recovery of functions is achieved
72	Birth injury to the peripheral nervous system (P14)	twice a year	twice a yearneurologist	Complete blood count, general urine analysis, electroencephalography	Twice a year	observation until complete or partial recovery of functions is achieved
Congenital anomalies (malformations) of the eye, ear, face and neck
73	Microcephaly (Q2)	once a year	twice a yearneurologist	Electroencephalography, ophthalmoscopy	twice a year	observation until complete or partial recovery of functions is achieved
				Skull X-ray	once a year
74	Anophthalmos, microphthalmos and macrophthalmos, congenital, after removal of eyes for other ophthalmic pathology, (Q11)	once a year	once a year ophthalmologist	Visometry	once a year	for life
				Ophthalmoscopy
				Biomicroscopy
				Perimetry
75	Congenital ear defects causing hearing impairment (Q16)	once a year	once a year otorhinolaryngologist	Tonal threshold audiometry	once a year	for life
76	Congenital cleft palate and lip (Q35-Q37)	from birth to 6 months monthly, from 6 months to 6 years 1 time in two months and according to indications	once a year surgeon (maxillofacial surgeon)	Complete blood count, determination of total protein	once a year	deregistration after restoration of the anatomical integrity of tissues
77	Congenital malformations and deformities of the musculoskeletal system (Q65-Q79)	once a year	once a year traumatologist-orthopedist	Determination of rheumatoid factor in blood serum quantitatively on the analyzer	once a year	restoration of functional range of motion in the joint
				Radiography of one segment
Trauma
78	Head injury (S06)	twice a year	twice a yearneurologist	General blood test, general urine analysis, determination of blood glucose, total cholesterol	once a year	observation until complete or partial recovery of functions is achieved
				Doppler ultrasonography of cerebral vessels	once a year
				MRI of the brain	according to indications (once every 2 years)
79	Injury of the abdomen, lower back, lumbar spine and pelvis (S30-S39)	once a year	once a year traumatologist-orthopedist	Control radiographs of the affected segment	at 6, 12 and 36 weeks after surgery	observation until complete or partial recovery of functions is achieved
				CT scan of the spine	according to indications (once every 3 years)
Condition after organ and tissue transplantation
80	Transplanted organs and tissues (Z94)	1 time per month	Specialist in indications	Complete blood count, general urine analysis	1 time per month	for life
				Tacrolimus / CsA level	Once a month (up to 12 months)
				Additional laboratory and instrumental research methods according to clinical diagnostic and treatment protocols

Appendix 2 to the order

List of some orders of the Ministry of Healthcare of the Republic of Kazakhstan that have become invalid

1) order of the Minister of Health of the Republic of Kazakhstan dated March 30, 2019 No. RK MH-16 "On approval of the Rules for dynamic observation of patients with chronic diseases" (registered in the Register of State Registration of Normative Legal Acts on April 8, 2019 under No. 18474, published on April 16, 2019 in the Reference Control Bank of regulatory legal acts of the Republic of Kazakhstan in electronic form);

2) order of the Minister of Health of the Republic of Kazakhstan dated October 17, 2019 No. RK MH-136 "On approval of the list of chronic diseases, in which dynamic observation of patients is carried out, the list of socially significant diseases for which medical and social assistance is provided, the list of diagnostic services, including number of laboratory diagnostics, a list of infectious diseases and diseases that pose a danger to others, a list of diseases that are not subject to dynamic monitoring within the guaranteed volume of free medical care, a list of certain categories of the population subject to emergency and planned dental care, a list of diseases (conditions) subject to medical rehabilitation and restorative treatment in the direction of a specialist in primary health care or a medical organization "(registered in the Register of State Registration of Normative Legal Acts on October 18, 2019 under No. 19484,published on October 18, 2019 year in the Reference Control Bank of regulatory legal acts of the Republic of Kazakhstan in electronic form).