Recommendations for students on filling out a medical record of a dental patient with defects of hard dental tissues at the Department of Orthopedic Dentistry. Medical card Examples of preparing an outpatient card for a dental patient

AT THE DEPARTMENT OF ORTHOPEDIC DENTISTRY

Medical record of a dental patient

The main document for recording the work of a dentist of any specialty is the medical record of a dental patient, form 043-u, approved by order of the USSR Ministry of Health No. 000 dated 01/01/2001.

A medical card (outpatient card or medical history) is a mandatory document for a medical outpatient appointment that performs the following functions:

· is a plan for a thorough examination of the patient;

Count "Allergological history" The patient is asked whether there have been any allergic reactions to medications, household chemicals, food products, etc., whether anesthesia has been used previously, and whether any complications have been noted after it.

To diagnose the pathological condition of the dental system, a thorough study must be carried out patient's dental status followed by a detailed description of it in the medical record.

In concept "dental status" includes data from the patient’s external examination and examination of his oral cavity.

When describing the results of an external examination, special attention should be paid to:

· signs of changes in proportions - a decrease in the height of the lower part of the face, which may be due to significant destruction of a large number of chewing teeth, increased abrasion of hard dental tissues;

· nature of movements of the lower jaw;

· the nature of the movements of the heads of the temporomandibular joints (which is determined by palpation).

Example: The face is symmetrical and proportional. Full mouth opening. Movements of the lower jaw are free and uniform.

When describing the results of an examination of the patient’s oral cavity, fill in dental formula, which is a two-digit system in which the quadrants (segments) of the jaws and each tooth of the jaw are numbered alternately (from right to left on the upper jaw and from left to right on the lower jaw). Teeth are numbered from the midline. The first number indicates a quadrant (segment) of the jaw, the second number indicates the corresponding tooth.

Example:

PWithRShtZ P K K

1812 11 !26 27 28

4842 41 !36 37 38

S PP K K

In the dental formula, in accordance with the symbols, all teeth are noted ( P– sealed; WITH– with carious cavities, R – with significantly or completely destroyed coronal part); degree of tooth mobility ( 1, P, Sh, 1U), teeth with orthopedic structures ( TO– artificial crowns, ShtZ– pin tooth) etc.

Under the dental formula, additional data is recorded regarding the teeth that are subject to restoration by orthopedic methods: the degree of destruction of the coronal part, the presence of fillings and their condition, changes in color and shape, position in the dentition and relative to the occlusal surface of the dentition, exposure of the neck, stability (or degree of mobility) , results of probing and percussion. The condition of the marginal periodontium is described separately, in particular, changes in the gingival margin (inflammation, recession), the presence of a gingival pocket, its depth, and the ratio of the extra- and intra-alveolar parts of the tooth.

Example:

16 – there is a filling on the chewing surface, the marginal seal is broken, the neck of the tooth is exposed, the tooth is stable, percussion is painless.

14 – on the medial surface there is a small carious cavity; probing the cavity is painless.

13 – there is a complete absence of the crown part of the tooth, the root protrudes above the gum level by 0.5-1.0 mm, the root walls are of sufficient thickness, dense, without pigmentation, the root is stable, percussion is painless, the marginal gum without signs of inflammation, tightly covers the neck of the tooth.

11 – artificial metal-plastic crown, plastic lining is discolored, hyperemia of the marginal edge of the gums is noted.

21 – the coronal part is discolored, the medial corner of the incisal edge is chipped, the tooth is stable, located in the dental arch, percussion is painless.

26, 27, 37, 36 – artificial all-metal crowns in satisfactory condition, tightly covering the necks of the teeth, marginal gums without signs of inflammation.

31, 32, 41, 42 – dental plaque, slight hyperemia of the gingival margin.

45 – the filling on the occlusal surface is of satisfactory quality, the marginal fit of the filling is not broken, percussion is painless.

46 – on the occlusal surface there is a large filling, changed in color; probing reveals a violation of the marginal seal, a chip of the medial lingual tubercle, the tooth is stable, percussion is painless.

In the column "Bite" record data on the nature of the relationship of the dentition in the position of central occlusion, the depth of overlap in the anterior section and the identified deformation of the occlusal surface of the dentition.

Example:The bite is orthognathic. The crowns of the upper front teeth overlap the lower teeth by more than 1/3. Violation of the surface of the closure of the dentition due to the advancement of the 46th tooth relative to the occlusal surface by 1.5 mm (or by ¼ of the height of the crown). There is hypertrophy of the alveolar process in the area of ​​46, exposure of the neck of the tooth.

In the column " Data from additional research methods » the results of x-ray examinations are recorded with a detailed description of x-rays of each tooth subject to orthopedic treatment. When “reading” x-rays, the condition of the tooth shadow is assessed and described according to the following scheme:

· condition of the crown – presence of a carious cavity, filling, relationship between the bottom of the carious cavity and the tooth cavity;

· characteristics of the tooth cavity - the presence of a shadow of filling material, instruments, denticles;

· condition of roots: number, shape, size, contours;

· characteristics of root canals: width, direction, degree and quality of filling;

· assessment of the periodontal gap: uniformity, width;

· condition of the compact plate of the socket: preserved, destroyed, thinned, thickened;

· condition of periapical tissues, analysis of the pathological shadow, determination of its location, shape, size and nature of the contour;

· assessment of surrounding tissues: condition of interdental septa – height, condition of the compact endplate.

Example:

On intraoral x-rays of satisfactory quality:

16 – a change in the position of the tooth relative to adjacent ones is determined (advancement by 1.5 mm in relation to the occlusal surface), in the coronal part of the tooth there is an intense shadow of the filling material, close to the tooth cavity, the marginal fit of the filling is broken, atrophy of the interdental septa up to 1/3 of the length roots

13 – absence of a coronal part; in the root canal, along the entire length of the canal to the apex of the root, there is a uniform, intense shadow of the filling material. The periodontal gap is not widened, there are no changes in the periapical tissues.

11 – in the area of ​​the coronal part, an intense shadow of the metal frame of the artificial crown is projected; in the root canal, up to ½ of its length, an intense shadow of a metal wire pin can be traced. In the apical third of the root canal, the shadow of the filling material is not visible. Uniform expansion of the periodontal fissure. In the area of ​​the root apex there is a focus of rarefaction of bone tissue with unclear contours in the form of “tongues of flame”.

21 – chipping of the medial corner of the cutting edge of the coronal part; in the root canal there is an intense shadow of filling material with filling defects. No changes were detected in the periapical tissues.

46 – in the area of ​​the tooth crown there is a shadow of the filling material, located close to the tooth cavity, the marginal fit of the filling is broken, the root canals are free of filling material. There are no changes in the periapical tissues.

32, 31, 41, 42 – no pathology of hard tissues was detected, interdental septa were reduced to 1/3 of the length of the roots, there was an absence of compact end plates, the apexes had a “scalloped” appearance.

The same column describes the data of electroodontodiagnosis and other examination methods (for example, the results of tomography of the temporomandibular joints in patients with signs of declining occlusion).

Based on the data of the clinical examination and the results of additional research methods, a diagnosis . Accordingly, the column "diagnosis" in the medical record is filled out only after a complete examination of the patient.

When making a diagnosis, it is necessary to highlight:

· main disease of the dental system and complication of the main disease;

· concomitant dental diseases;

· general concomitant diseases.

The main diagnosis must be detailed, descriptive and correspond to the international classification of nosological forms of dental diseases based on ICD-10 C.

When formulating the main diagnosis, first of all, morphological changes in the dental system are distinguished, indicating the etiological factor (for example, partial defect of the coronal part of the 46th tooth of carious origin).

In some cases, the underlying disease (in the example given) partial defect of the crown part of the 46th tooth) may be accompanied by complications, in particular in the form of deformations of the occlusal surface of the dentition (change in the position of the 16th tooth – dentoalveolar lengthening of the 1st degree of P-a form in the area of ​​the 16th tooth), which should also be reflected in the diagnosis.

In the given example morphological part of the main diagnosis is formulated as follows:

“Complete defect of the coronal part of the 13th tooth of carious origin (IROPD more than 0.8). Functional and aesthetic failure of the artificial crown of the 12th tooth. Partial defect with a change in color of the hard tissues of the 21st tooth of traumatic origin. Partial defect of the coronal part of the 46th tooth of carious origin, complicated by deformation of the occlusal surface of the dentition of the upper jaw - dentoalveolar lengthening of the 1st degree of P-a form in the area of ​​the 16th tooth."

The second component of the main diagnosis is functional part, characterizing dysfunction and movement of the lower jaw. For example, “Aesthetic insufficiency of the dentition of the upper jaw”, « Functional deficiency of the lower jaw dentition», "Blocking the movements of the lower jaw."

In the example given, the full formulation main diagnosis as follows:

“Complete defect of the coronal part of the 13th tooth of carious origin (IROPD more than 0.8). Functional and aesthetic failure of the artificial crown of the 12th tooth. Partial defect with a change in color of the hard tissues of the 21st tooth of traumatic origin. Partial defect of the coronal part of the 46th tooth of carious origin, complicated by deformation of the occlusal surface of the dentition of the upper jaw - - dentoalveolar lengthening of the 1st degree of P-a form in the area of ​​the 16th tooth. Functional and aesthetic insufficiency of the dentition, blocking the movements of the lower jaw in anterior occlusion.”

IN concomitant dental diagnosis All identified dental pathologies are removed, the treatment of which will be handled by dental therapists, dental surgeons, orthodontists (for example, caries, chronic periodontitis, gingivitis, periodontitis, diseases of the oral mucosa, etc.).

Example: « Deep incisal overlap. Chronic localized catarrhal gingivitis in the area of ​​teeth 11, 32, 31, 41, 42. Dental caries 14, 47.”

IN concomitant somatic diagnosis somatic diseases of the cardiovascular, endocrine, nervous systems, respiratory organs, gastrointestinal tract, etc. are noted.

Depending on the formulation of the diagnosis, a treatment plan , which, in addition to the actual orthopedic treatment of a defect in the hard tissues of the tooth, may include preliminary preparation of the oral cavity for prosthetics. Preparation of the oral cavity for orthopedic treatment includes are common(rehabilitation) and special measures (therapeutic, surgical, orthopedic, orthodontic).

Sanitation measures are carried out if the accompanying dental diagnosis indicates the presence of teeth to be treated (caries, chronic periodontitis), diseases of periodontal tissues (dental deposits, gingivitis, periodontitis in the acute stage), diseases of the oral mucosa, etc.

Example: “The patient is sent for sanitation of the oral cavity before prosthetics: treatment of teeth 14, 17, removal of dental plaque, treatment of gingivitis. Professional oral hygiene is recommended.”

Special dental preparation It is performed according to prosthetic indications and is necessary for more effective orthopedic treatment and to eliminate the possibility of complications developing after treatment.

Before orthopedic treatment of defects in hard dental tissues, special therapeutic measures preparation of teeth, among which it should be noted:

· refilling of root canals;

· depulpation of teeth planned for orthopedic construction (for example, if radical preparation of teeth with a wide cavity is necessary, with tilting or vertical movement of teeth);

· preparation of root canals for pin structures (unsealing of root canals).

The ultimate goal of orthopedic treatment of hard tissue defects is to restore:

· anatomical shape of the tooth crown;

· unity of dentition;

· lost functions and aesthetics.

In this regard, in the column "Treatment Plan" The designs of dentures with the help of which the goal of orthopedic treatment will be realized must be indicated.

Example:

“Restore the anatomical shape of the coronal part

tooth 16 – cast all-metal crown;

teeth 13, 11 – metal-ceramic crowns on cast cores

pin tabs;

tooth 21 – metal-ceramic crown;

tooth 46 – cast all-metal crown on a cast stump pin insert.

If it is necessary to carry out special preparation of a tooth for prosthetics, the planned activities should also be described in detail in the column "Treatment plan."

Example:

1. In order to eliminate deformation of the occlusal surface of the dentition of the upper jaw, it is recommended to depulpate the 16th tooth, followed by its grinding (shortening) and restoration of its shape with a cast all-metal crown.

2. Restore the anatomical shape of the crown of the 13th tooth with a cast stump pin and a metal-ceramic crown with preliminary preparation of the root canal for the cast stump pin (unsealing 2/3 of the length).

3. Restore the anatomical shape of the coronal part of the 11th tooth with a cast stump pin and metal-ceramic crown with preliminary revision, refilling and preparation of the root canal for the cast stump pin.

4. Restore the anatomical shape of the coronal part of the 21st tooth with a metal-ceramic crown with preliminary refilling of the root canal using a fiberglass pin.

5. Restore the anatomical shape of the crown of the 46th tooth with a cast stump pin insert and a cast all-metal crown with preliminary depulpation of the tooth and preparation of channels for the cast stump pin insert.

The patient should be informed by the doctor about all possible options for dental prosthetics and the most optimal method of treatment in a given clinical situation, about treatment planning (including the need to prepare the oral cavity for prosthetics for orthopedic indications). An appropriate entry should be made in the medical history (preferably by the patient himself and with his signature) with the following wording: “ I am familiar with the options for prosthetics and agree with the prosthetics plan (including the preparation plan for prosthetics).

In chapter "Diary» the clinical stages of orthopedic treatment are described, indicating the date of the patient’s appointment and the date of the next appointment. Here are examples of filling "Diary" depending on the design of the denture in the orthopedic treatment of defects in the hard tissues of teeth.

The final section of the medical history of a dental patient "Epicrisis" filled out according to a specific pattern:

Patient (full name) 02/27/09 went to the orthopedic dentistry clinic with complaints about _______________________________________.

Based on the examination data, the following diagnosis was made: _________________________________________________________________.

Orthopedic treatment was carried out ___________________________________

____________________________________________________________

The anatomical shape of the tooth crowns, the integrity of the dentition of the upper jaw, lost functions and aesthetic standards have been restored.

The medical history is completed by the signature of the doctor and, preferably, the head of the department.

A medical card is a mandatory document for each medical institution. It summarizes information about the client’s health, being an integral part of the clinic’s document flow.

Filling it out correctly guarantees the preservation of information about a person’s health, treatment and its results. A dental patient's medical record has important features, so you need to know what it is and how it is filled out.

What is it, what distinguishes it from a regular medical record?

An outpatient card is a standard document that includes basic information about the client, medical history, diagnosis and course of treatment. This is one of the main primary documents in a medical institution, allowing you to systematize information. It also has important legal significance, allowing one to prove the case in controversial situations.

An important feature of a dental medical record and its difference is its highly specialized focus - it reflects the person’s condition.

Legislative framework: understanding the orders

Form 043/у is established by Order of the USSR Ministry of Health No. 1030. By letter dated November 30, 2009, the Ministry of Health and Social Development of the Russian Federation recommended this form for use by dentists. It is uniform for both public dental clinics and commercial ones.

Since form 043/у is approved at the legislative level, it is a reporting document.

Sample form 043/у:

Modifications to form 043/у are undesirable, since in controversial situations, for example, in litigation, the evidence will be taken into account from the outpatient card of the dental patient according to the established template.

If necessary, information tabs are pasted into the card printed according to the established template, which complement the content without changing the form itself.

Content - no encryption

Form 043/у has three parts. The first contains passport information:

• number and date;
• Full name, date of birth of the patient;
• address;
• job title;
• diagnosis by a dentist;
• chronic diseases.

The second part of the medical record specifies the diagnosis and examination details:

• examination by a dentist;
• features of dental condition;
• features of bite;
• laboratory test results and radiographic examination data.

The third part contains:

• instructions and recommendations;
• opinions of other highly specialized specialists.

Templates for some card pages:

Sample dental patient treatment plan:

This is what the dental examination certificate form looks like:

Filled out by whom and how - no one deviates

Dental card forms exist in electronic form, which can be printed either directly in the clinic or ordered printed from a specialized organization. The outpatient card is filled out by clinic staff.

The passport information in the first part is filled out by the administrator of the dental clinic during the client’s initial visit, or by the nurse during the initial examination of the dental patient.

The second and third parts are directly related to the diagnosis and treatment regimen, medical history, therefore only a dentist has the right to fill them out.

As part of the automation of the process, electronic services are being created that make it possible to save electronically data on medical interventions, dental treatment and reactions to anesthesia, dates of requests and appointments, and the results of radiographic examinations. Electronic medical dental records of the patient can be filled out along with paper medical records. If a dental clinic maintains electronic document flow, this does not cancel its obligation to fill out form 043/у on paper.

What information is entered and what is transferred?

After the dentist conducts an examination and the test results appear, information is entered in the “diagnosis” column. The date is indicated.

Requirements for diagnosis: detailed and descriptive in nature regarding the condition of the teeth and oral cavity as a whole.

Describing the disease, the doctor specifies the time of the first signs, the course, the patient’s complaints, what treatment was carried out and with what result.

Diseases can be noted on a special insert, which is a. When the patient returns again, entries must be made in the card diary.

Entries must be made in legible handwriting; blots and corrections are excluded. Filling out can be done either by hand or by typewriting - printed sheets are pasted into the medical record.

The attending physician records the dates of admission, the course of the disease and the effectiveness of the treatment, prescribed medications, and procedures. Common names and abbreviations are used. All relevant information is entered after the patient is admitted.

In addition to the required data, the following information can be entered:

• opinions of dentists from other medical institutions;
• results and data on the degree of exposure during such examination;
• test results.

Now patients have the opportunity to maintain a personal medical record and communicate with their attending physician using the Medkarta24 platform. There is a similar platform for readers from Ukraine.

Where is it stored, where can it hide?

This patient's medical dental record contains personal health data, their safety is guaranteed by law. When a client first contacts dentistry, he signs consent to the storage, recording and processing of personal information and his personal data. Only if there is consent, the storage of such information by the clinic will be considered legal. Providing the patient’s personal data to other persons is possible only if he has given permission to do so, or if there is a court order.

A dental patient's outpatient card is stored in the dental clinic for 5 years, which is calculated from the date of the client's last visit. Then it is handed over to the archives.

Letter of the Ministry of Health and Social Development of the Russian Federation dated 04.04.2005 N 734/MZ-14 allows the card to be issued to the patient - but only with the permission of the head physician of the institution. The refusal may be motivated by the fact that this medical documentation is the property of dentistry, as well as a document of strict accountability.

At the same time, the client has the right to obtain information about his health. He has the right to familiarize himself with his card. Upon request, he may be provided with extracts and copies containing information about the types of medical intervention, treatment and examination. In this way, the client will be able to obtain complete information without taking the medical record outside the threshold of the medical institution.

Sample extract from the card:

If a patient arranges a transfer from one clinic to another under a compulsory medical insurance policy, there is no need to require the patient’s card to be issued in person - the clinic receiving the patient will itself request documentation from the clinic that previously served the patient. The transfer of the patient's hospital record is carried out by the clinic management within three days.

The current form 043 y was developed, approved and put into circulation on October 4, 1980. The body that approved the document is the USSR Ministry of Health. The form is used by outpatient dental institutions as the main accounting document for recording data about patients and the progress of treatment.

A dental patient card form 043 is issued for all citizens who seek help. The document exists in one copy for each patient. The number of specialists who took part in the treatment of the patient does not matter. All data is compiled into one card.

Card form 043 y is produced in A5 format. This is a notebook that includes a title page and pages with ready-made columns for entering data. The form includes an agreement for the provision of dental services, which must be signed by the patient after reading the text of the agreement. The title page must contain the exact full name of the institution. Each card has its own unique individual number.

The dental patient card form 043 must contain the patient’s passport data. This sheet is filled out at the registration desk. The basis is documents proving the identity of the applicant. The patient enters information about his health into the card.

Information about your health status should include such important parameters as the presence of allergies, blood type and Rh factor, chronic diseases of internal organs, existing head injuries, medications currently taken, etc. It is extremely important to provide as much information as possible. This will help the specialist choose the safest and most effective treatment.

Diagnosis of diseases of the teeth and oral cavity may include both visual examination and x-ray examinations. The use of an X-ray machine involves exposing the patient to radiation. The received radiation dose must also be recorded in the card.

Pages with examination results, data on diagnosis and treatment progress are filled out by specialists performing the relevant procedures. The patient must document his or her agreement to the examination and treatment plan.

An important feature of filling out the form is the ability to write down the names of drugs in Latin. The rest of the information is entered only in Russian. Text entered by hand must be legible. Corrections are confirmed by signature.

Medical card 043 y is the property of the clinic.

According to the instructions, dental card form 043 is not issued in person. This legal document can be used in the event of litigation or claims from the patient. In an outpatient dental facility, the card is stored for 5 years. After this period, the form is transferred to the organization’s archives. The archival storage period is 75 years.

Unlike most established forms of medical forms, Form 043 is advisory. The form can be supplemented and adjusted to suit the needs of a specific medical institution. In the City Blank printing house it is possible to order such an adjustment of the form, taking into account all the customer’s requirements.

The document can be shortened, supplemented, and columns adjusted. To preserve the protective functions of the document, it is recommended not to exclude important points of the form, for example, an agreement on consent to the provision of services, data on the primary diagnosis. The completeness of the data confirms the quality of the services provided.

You can buy a dental patient’s medical record either in a single copy or in a batch of the required volume. For institutions in Moscow and the Moscow region, delivery by courier is possible. Non-standard forms are printed after final approval.

A medical record of a dental patient is not just a document, but one of the main means of resolving conflicts with patients for a medical organization, along with a contract and informed consent.

Let me note that this tool may be ineffective if maintaining a dental patient’s medical record is not taken seriously enough. There is an expression that the doctor writes a medical record for the prosecutor, in fact, the doctor writes it exclusively for himself, for his peace of mind, since the patient’s medical record is, first of all, a kind of support and confidence. After all, if a doctor goes to court, even as a witness or expert, it is always a huge stress, so the main task of correctly filling out a medical record is to ensure that the situation does not reach the court.

If we talk about the effectiveness of a medical record as a means of protection, then we can distinguish two equally important blocks: the form of the medical record and its content.

Dental patient medical record form

New medical documentation forms were approved by order of the Russian Ministry of Health No. 834n dated December 15, 2014. Before this, forms were used for a long time according to order No. 1030 of October 4, 1980, which was adopted by the USSR Ministry of Health, since it largely met the necessary requirements. The new order is often illogical; it now contains about 12 forms, but it is not always clear why exactly they were included in the order. For example, there is no general form for a dental patient. But there appeared an orthodontic record of a dental patient, which was largely developed for scientific activities.

One frequently asked question is: Can a dental patient record form be supplemented? You can add additional information to it, but it is advisable not to remove from there what is there. Whether you will fill out everything completely is another question, but it is better to leave the columns themselves. Otherwise, a competent lawyer will say that the medical record form is not approved and cannot be evidence in court because it does not comply with the requirements of the law.

Also, sometimes questions arise about the use of electronic medical records, and everyone has three completely different things in mind:

The first option is a situation where you have specialized software, where you enter patient data into the program, then print out the already completed form. The form is signed by the doctor and the patient and is pasted into the medical record. This is a valid option, the best one today, because the program, as a rule, takes a lot into account and everything is clear.

The second option also uses software, but the dental patient’s medical record is maintained only in electronic form, it is stored in the computer’s memory and is not printed. If a conflict situation arises in court, such a medical record will most likely be considered inadmissible evidence.

The third, ideal option, which is envisaged by the state health care development program until 2020, is the “Electronic Medical History”. If you want to keep a medical record only in electronic form, then it must comply with GOST “Electronic medical history”, but this is not so easy to do. Uninterrupted electrical power must be provided with the possibility of constant access, the protection of personal data and the impossibility of losing information must be proven. It is also necessary that patients and doctors can digitally sign this electronic document. Very rarely all these conditions are met.

The language of the medical record is Russian. If you want to use a foreign word, it is better to replace it with an alternative Russian one. Doctors often use English and Latin terms that are not always clear to the patient, and he must understand everything that is written in his chart. This also applies to abbreviations, of course, there are official, generally accepted abbreviations, but sometimes doctors abbreviate much more than is generally accepted. In this case, you need to make a list of your abbreviations, print it out and paste it into the card so that the client understands them too.

As for corrections made to the card: the use of a stroke, “doodles”, sticking over pieces of the medical card - all of the above is unacceptable. A medical record of a dental patient with such corrections cannot be assessed by experts as proper evidence, and as a result, it will be interpreted not in favor of the doctor.

You might be interested

• Checking a patient's complaint against a dental clinic

Here you should use a simple formula that is easy to remember: Given + What you did = Result.

1. “Given” is what the patient comes to your clinic with. “Given” means complaints described in detail, always in detail. Write down all complaints, pain, describe the oral cavity in detail, especially if the patient came from another clinic, because in the event of a lawsuit, getting an extract from there will be quite problematic. You immediately need to record the situation with which the patient came. “Given” also includes an x-ray, its mandatory description. If you are doing large-scale work in the clinic on orthopedics, orthodontics, or surgery, it is advisable that you have a radiologist at least a quarter of the time, or a half-time one. “Given” includes photographs of treatment, that is, photo-logging, which is carried out where the aesthetic result is important, there must be “before” photographs. If there is no fixation of what is given, then it is impossible to evaluate the result.
2. “What they did” - a detailed description of what manipulations were carried out, with what help; The more detail you describe, the more significant the role this record will play in protecting the doctor.
3. Result. Mandatory photo recording, if the aesthetic aspect is important, mandatory recording of the recommendations that you give to the patient to preserve the result obtained. A recommendation is the most powerful thing in defending a medical organization in court. If recommendations were prescribed, and the patient ignored them, then in court all charges against the clinic may be dropped. In order for recommendations to save you, two factors must be taken into account. You must prove that:

• you gave recommendations
• these recommendations were not implemented.

Therefore, the recommendations must have the client’s signature, and the phrase: “Recommendations have been given” will not help in this situation. The result also includes notifications of required appearances; this is also a point that is taken into account in court. Recommendations can be written down in the medical record each time, or you can develop a single list that will contain all the recommendations regarding the manipulations that you carry out, and the patient only signs, confirming that he is familiar with them.

Notify patient of required appearances. If the date of appearance and the fact of no-show are recorded, this also works in favor of the clinic in conflict situations. Also, if the patient does not show up for the scheduled appearance, and you know that his situation is difficult, then you should send him 2-3 telegrams (registered letters) to again prove in court that you did everything in your power and were interested in his arrival.

The diagnosis must be made according to ICD-10. This may not be very convenient for dentists, who have their own classification, but it is important for experts. You can write diagnoses in the chart according to both classifications: the generally accepted ICD-10 and the dental one.

A very important point is agreeing on the treatment plan and changing it. We are talking about long-term manipulations (orthopedists and orthodontists), where you practically cannot give strict deadlines, situations where the price may change because one of the treatment methods did not work. It is imperative to write down the initial plan, with deadlines and price, and make all changes accompanied by the patient’s signature, because your patient is also a consumer, and according to the law on consumer protection, you need to agree with him on the type of work, volume, deadline and price. It is also necessary to specify the warranty periods, as well as the reasons why they were reduced, if this happened.

Storage periods for a dental patient's medical record

According to the new rules, the patient’s medical record must now be stored not for 5 years (Order of the USSR Ministry of Health No. 1030 of October 4, 1980), but for 25 years (Letter of the Ministry of Health of the Russian Federation of December 7, 2015 No. 13-2/1538).

According to Order of the Ministry of Health of the Russian Federation No. 203n dated May 10, 2017: proper completion of a medical record is one of the criteria for the quality of medical care.

Don’t forget, the medical record has actually become part of the contract with the patient. It is necessary to have the patient’s signature on the card; this is confirmation of complaints, medical history, services provided, recommendations, and the need to appear.

• Afanasyev V.V., Barer G.M., Ibragimov T.I. Dentistry. Recording and maintaining a medical history: A practical guide. M.: VUNMC Roszdrav, 2006.
• Saversky A.V. Patients' rights on paper and in life. M.: EKSMO, 2009.
• Salygina E.S. Legal support for the activities of a private medical organization. M.: Statute, 2013.
• Sashko S.Yu., Ballo A.M. Legal assessment of defects in the provision of medical care and maintenance of medical records. St. Petersburg: CNIT, 2004.