Card design. Medical record of a dental patient: rules for registration and storage Registration of an orthopedic doctor’s card

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.

		Last name of the attending physician
Orthopedic treatment using a stamped metal crown
	Preparation of the 27th tooth for a stamped metal crown. Obtaining a working two-phase impression using silicone impression material (for example, Speedex) and an auxiliary impression from the lower jaw with alginate impression mass (for example, Cromopan). Turnout 03/01/09.
	Fitting a metal stamped crown for 27 teeth. No comments. Turnout 03/02/09
	Final fitting and fixation of a stamped metal crown for 27 teeth with phosphate cement (for example, Unicem). Recommendations are given.
Orthopedic treatment using a plastic crown
	Preparation of 21 teeth for a plastic crown. Obtaining a working two-phase impression using silicone impression material (for example, Speedex Cromopan) from the lower jaw. Selecting the color of the plastic according to the Sinma plastic color scale (for example, color No. 14). Turnout 03/01/09
	Fitting a plastic crown with correction of occlusal relationships and fixing it on 21 teeth with glass ionomer cement (for example, Fuji). Recommendations are given.
Orthopedic treatment using a combined metal-plastic crown according to Belkin
	Under infiltration anesthesia with 0.5 ml of a 4% solution of articaine with epinephrine, the 11th tooth was prepared for a stamped metal crown. Obtaining a two-phase impression with silicone impression material (for example, Speedex) from the upper jaw and an auxiliary impression with alginate impression mass (for example, Cromopan) from the lower jaw. Turnout 03/01/09
	Fitting a metal stamped crown for 11 teeth. Under infiltration anesthesia with 0.7 ml of a 4% solution of articaine with epinephrine, additional preparation of the cutting edge of the vestibular and proximal surfaces of the 11th tooth was performed. Obtaining an imprint of the stump of the 11th tooth in a crown filled with wax. Obtaining a single-phase impression from the dentition of the upper jaw with a metal crown fitted with silicone impression mass (for example, Speedex). Selecting the color of the plastic cladding according to the Sinma plastic color scale (for example, color No. 14 + 19). Turnout 03/03/09.
	Final fitting of the metal-plastic crown and fixing it on the 11th tooth with glass ionomer cement (for example, Fuji). Recommendations are given.
Orthopedic treatment using a cast all-metal crown
	Under general anesthesia with 1.0 ml of a 4% solution of articaine with epinephrine, the 37th tooth was prepared for a cast all-metal crown. Gum retraction using a mechanochemical method using a retraction cord impregnated with epinephrine. Obtaining a working two-phase impression using silicone impression compound (for example, Speedex) from the upper jaw and an auxiliary impression with alginate impression mass (for example, Cromopan) from the lower jaw. Turnout 03/04/09.
	Checking the quality of a cast all-metal crown, fitting it to the stump of the 37th tooth with correction of occlusal relationships in the central, anterior and lateral occlusions. No comments. Turnout 03/06/09.
	Final fitting of the cast all-metal crown and its fixation on the 37th tooth with glass ionomer cement (for example, Fuji). Recommendations are given.
Orthopedic treatment using a metal-ceramic crown
	Under infiltration anesthesia with 1.3 ml of a 4% solution of articaine with epinephrine, teeth 11 and 21 were prepared for metal-ceramic crowns. Gum retraction using impregnated retraction cords. Obtaining a working two-phase impression using silicone impression compound (for example, Speedex) from the upper jaw and an auxiliary impression with alginate impression mass (for example, Cromopan) from the lower jaw. Fitting and fixing standard temporary provisional crowns on the stump of 11, 12 teeth with water-based dentin. Turnout 03/04/09.
	Fitting of cast metal caps on supporting teeth 11, 21. Selecting the color of the ceramic coating according to the Chromascope color scale. Fixation of temporary provisional crowns on the stump of 11, 12 teeth with water-based dentin. Turnout 03/06/09.
	Checking the design and fitting metal-ceramic crowns for teeth 11 and 21. Correction of occlusal relationships in central, anterior and lateral occlusions. No comments. Fixation of temporary provisional crowns on the stump of 11, 12 teeth with water-based dentin. Turnout 03/07/09.
	Final fitting and fixation of metal-ceramic crowns on the supporting teeth 11, 21 with glass ionomer cement (for example, Fuji). Recommendations are given.
Orthopedic treatment using an artificial crown on a cast stump pin inlay made by direct method
	Preparation of the stump of the 13th tooth. Root canal preparation. Modeling a pin insert with wax Lavax. Temporary filling made of water-based dentin. Turnout 03/04/09.
	Fitting and fixing the cast stump pin insert in the root canal of the 13th tooth with phosphate cement (for example, Uniface). Turnout 03/05/09.
	Additional preparation of the stump of the 13th tooth. Gum retraction using a retraction cord impregnated with epinephrine. Obtaining a working two-phase impression using silicone impression compound (for example, Speedex) from the upper jaw and an auxiliary impression with alginate impression mass (for example, Cromopan) from the lower jaw for the manufacture of a metal-ceramic crown for the 13th tooth. Fitting and fixing a standard temporary provisional crown on the stump of the 13th tooth with water-based dentin. Turnout 03/09/09.
	Checking the design and fitting the cast metal cap to the stump of the 13th tooth. Selecting the color of the ceramic coating according to the Chromascope color scale. Fixation of a temporary crown on the stump of the 13th tooth with water-based dentin. Turnout 03/12/09.
	Checking the design and fitting the metal-ceramic crown for 13 teeth. Correction of occlusal relationships in central, anterior and lateral occlusions. No comments. Fixation of a temporary provisional crown on the stump of the 13th tooth with water-based dentin. Turnout 03/13/09.
	Final fitting and fixation of the metal-ceramic crown on the stump of the 13th tooth with glass ionomer cement (for example, Fuji). Recommendations are given.
Orthopedic treatment using an artificial crown on a cast stump pin inlay made indirectly
	Preparation of the stump of the 26th tooth. Preparation of root canals. Introduction of corrective silicone impression mass (for example, Speedex) into the root canals using a canal filler. Obtaining a two-phase impression with imprints of root canals using silicone impression compounds Speedex. Temporary filling made of water-based dentin. Turnout 03/04/09.
	Fitting a dismountable stump pin insert with a sliding pin in the root canals of the 26th tooth, its fixation with glass ionomer cement (for example, Fuji). Turnout 03/05/09.
	Additional preparation of the stump of the 26th tooth. Gum retraction using impregnated retraction cord. Obtaining a working two-phase impression from the upper jaw with silicone impression material (for example, Speedex), auxiliary – with lower alginate impression mass (for example, Orthoprint) for the manufacture of a cast all-metal crown for the stump of the 26th tooth. Turnout 03/06/09.
	Checking the design and fitting the cast all-metal crown on the stump of the 26th tooth. Correction of occlusal relationships. No comments. Turnout 03/07/09.
	Final fitting and fixation of the cast all-metal crown on the artificial stump of the 26th tooth with glass ionomer cement (for example, Fuji). Recommendations are given.

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.

Card design standards (Moscow)

1).Medium caries:

Complaints: short-term pain from cold, sweet food.....(tooth formula)

Objectively: on…..(name) surface…..(tooth formula) is carious

cavity ..... Black class, made of softened dentin. Probing is painful along the dentinal-enamel border. Short-term pain from temperature stimuli. Percussion is negative.

Treatment: under topical anesthesia (................................... (name)) and

infiltration (conduction) anesthesia (…… (name)) is formed

and the cavity was treated with medication. ….(description of the

manipulations - filling (number of surfaces). restoration, tab, etc., with the name of the material and color indication)

2).Deep caries:

Complaints: the presence of a carious cavity, food ingress, short-term pain from cold in.....(tooth formula).

Objectively: on….(name) surface…(tooth formula) there is a carious cavity,…..according to Black, filled with softened dentin. Probing is slightly painful along the entire bottom of the carious cavity. Short-term pain from temperature stimuli. Percussion is negative.

Treatment: Under topical anesthesia (.... (name)) and

Infiltration (conduction) anesthesia (….. (name)) is formed

and the cavity was treated with medication. Medical pad.. (name).

Insulating gasket…. (Name). (description of the manipulations performed - filling, restoration, inlay, etc., with the name of the material and an indication of the color). Sanding,

polishing

3).Exacerbation of chronic pulpitis.

Complaints: Pulsating, prolonged pain, aggravated by temperature stimuli in... (tooth formula). Night pain.

Objectively: on…. (name) surface...(tooth formula) carious cavity filled with softened dentin, filling remains, food debris. Probing is sharply painful at one point. When probed, the pulp bleeds. Temperature stimuli cause sharp, trace pain. Percussion is negative.

Treatment: Under topical anesthesia….(name) and

with infiltration (conduction) anesthesia….. (name) the tooth cavity is opened. Amputation, extirpation. Root canals are mechanically and medicinally treated. Length (mm).... ISO..... Sealed (description of materials and technology)

Second visit: No complaints

Treatment: ....(description of manipulations, pin, gasket, filling, restoration, tab indicating materials and color)

4).Chronic fibrous pulpitis.

Complaints: the presence of a carious cavity, periodic spontaneous pain in.. (tooth formula).

Objectively: On...(name) surface....(tooth formula) there is a deep carious cavity communicating with the tooth cavity. Probing is slightly painful. When probing the pulp bleeds. Percussion is negative.

Treatment: Under application anesthesia...(name) and infiltration (conduction) anesthesia...(name) the tooth cavity is opened. Amputation, extirpation. Root canals are mechanically and medicinally treated. Length (mm).... ISO..... Sealed....(description of materials and technology).

RVG control: the root canal is obturated uniformly and tightly along its entire length to the physiological opening. Temporary bandage.

Second visit:

No complaints.

Objectively: the temporary dressing has been preserved. Percussion is negative.

Treatment: ... (Description of manipulations: pin, gasket, filling, restoration, inlay, indicating materials and color)

5).Chronic gangrenous pulpitis.

Complaints: Pain from hot foods, presence of a carious cavity in....(tooth formula)

Objectively: on... (name) surface....(tooth formula) is deeply carious

a cavity filled with gray contents communicating with the tooth cavity.

Probing in root canals is painful.

.(description of materials and technology).

RVG control: the root canal is obturated uniformly and tightly along its entire length to the physiological opening. Temporary bandage.

Second visit:

No complaints

Objectively: The temporary dressing has been preserved. Percussion is negative. Treatment:...(description of manipulations: pin, gasket, filling, restoration, inlay, indicating materials and color)

6).Chronic hypertrophic pulpitis.

Complaints: Mild pain from mechanical stimuli, bleeding from

...(tooth formula).

Objectively: On the (name) surface....(tooth formula) there is a deep carious cavity filled with granulation tissue. On probing, the pulp is slightly painful and bleeds.

Treatment: Under topical anesthesia (name) and

Infiltration (conduction) anesthesia (name) opens the tooth cavity. Amputation, extirpation. The root canals are mechanically and medicinally treated. Length (mm).... ISO..... sealed (description of materials and technology).

RVG control: The root canal is obturated uniformly and tightly along its entire length to the physiological opening. Temporary bandage.

Second visit:

no complaints

Objectively: The temporary dressing has been preserved. Percussion is negative. Treatment: .(description of manipulations: pin, gasket, filling, restoration, inlay, indicating materials and color)

7).Exacerbation of chronic periodontitis.

Complaints of constant pain that increases when biting, a feeling of an “overgrown tooth.”

Objectively: on the (name) surface....(tooth formula) there is a deep carious cavity communicating with the tooth cavity. Probing is painless. Percussion is sharply positive.

Infiltration (conduction) anesthesia (name) opens the tooth cavity. Evacuation of contents from the root canal. Root canals are mechanically and medicinally treated. Length (mm).... ISO.... Temporary

Second visit:

No complaints.

Objectively: The temporary dressing has been preserved. Percussion is negative.

Treatment: Under topical anesthesia (Name) and infiltration (conduction) anesthesia (name), removal of the temporary dressing. Medical treatment of root canals. The root canals are filled (description of materials and technology).

RVG control. The root canal is obturated uniformly and tightly along its entire length to the physiological opening. Temporary bandage.

Third visit:

No complaints

Objectively: The temporary bandage is preserved. Percussion is negative.

Treatment: (description of manipulations: pin, gasket, filling, restoration, inlay, indicating materials and color)

8).Chronic fibrous periodontitis.

Complaints: the presence of a carious cavity in....(tooth formula) food ingress.

Objectively: on the (name) surface....(tooth formula), there is a deep carious cavity communicating with the tooth cavity. Probing is painless. Percussion is negative. There is no pain from temperature stimuli.

RVG: widening of the periodontal gap.

Treatment: Under topical anesthesia (Name) and

Infiltration (conduction) anesthesia (name) opens the tooth cavity. Evacuation of contents from the root canal. Root canals are treated mechanically and medicinally. Length (mm).... ISO.... Temporary bandage.

Second visit.

no complaints.

Objectively: The temporary dressing has been preserved. Percussion is negative.

Treatment: Under topical anesthesia (name) and

infiltration (conduction) anesthesia (name) removal of temporary bandage. Medical treatment of root canals. Root

The canals are sealed (description of materials and technology). RVG control. The root canal is obturated uniformly and tightly along its entire length to the physiological opening. Temporary bandage.

Third visit:

no complaints

Objectively: The temporary dressing has been preserved. Percussion is negative. Treatment: (description of manipulations: pin, gasket, filling, restoration, inlay, indicating materials and color)

9).Chronic granulating periodontitis.

complaints: The presence of a carious cavity in....(tooth formula), food ingress

Objectively: on the (Name) surface (tooth formula), there is a deep carious cavity communicating with the tooth cavity. Probing is painless. Percussion is negative. There is no pain from temperature stimuli.

RVG: expansion of the periodontal fissure, in the area of the apex (which root) there is a focus of destruction with unclear contours.

Treatment: Under application anesthesia (name) and infiltration (conduction) anesthesia (name), the tooth cavity is opened. Evacuation of contents from the root canal. The root canals are mechanically and medicinally treated. Length (crowbar).... ISO.... Temporary

Second visit:

no complaints.

Objectively: The temporary dressing has been preserved. Percussion is negative. Treatment: Under topical anesthesia (name) and infiltration (conduction) anesthesia (name) Removal of the temporary bandage. Medical treatment of root canals. Root canals are sealed.........(description of materials and technology)

RVG control: the root canal is obturated uniformly and tightly along its entire length to the physiological opening, temporary dressing.

Third visit:

no complaints

Objectively: The temporary dressing has been preserved. Percussion is negative. Treatment: ..(description of manipulations: pin, gasket, filling, restoration, inlay, indicating materials and color)

10).Chronic granulomatous periodontitis.

Complaints: The presence of a carious cavity in.... (tooth formula) food ingress.

Objectively: on (name) surface... (tooth formula), deep carious

cavity communicating with the cavity of the tooth. Probing is painless. Percussion is negative. There is no pain from temperature stimuli.

RVG: Widening of the periodontal fissure, in the area of the apex.... (which

root) focus of destruction with clear contours with a diameter of .. (mm)

Treatment: Under application anesthesia......(name) and infiltration (conduction)....(name) the tooth cavity is opened. Evacuation of contents from the root canal. The root canals are mechanically and medicinally treated. Length (mm)....ISO.temporary bandage.

Second visit:

no complaints.

Objectively: The temporary dressing has been preserved. Percussion is negative.

Treatment: Under topical anesthesia (name) and

infiltration (conduction) anesthesia (name) removal of the temporary dressing. Medical treatment of Root Canals. Root

The canals are sealed (description of materials and technology).

RVG control. The root canal is obturated uniformly and tightly along its entire length to the physiological opening. Temporary dressing.

Third visit:

no complaints

Objectively: The temporary dressing has been preserved. Percussion is negative. Treatment: .....(description of manipulations: pin, gasket, filling, restoration, tab indicating materials and color)

Average caries

complaints : for the presence of a carious cavity in the area…………… quickly passing pain from chemical irritants.

Sf/ loc . : in the area of …………… there is a carious cavity of medium depth with softened pigmented dentin, probing the enamel-dentin border is painful.

Deep caries

complaints :: for the presence of a carious cavity in the area of ……………, pain from chemical and thermal irritants, quickly disappearing after removal of the irritant.

Sf/1os.: in the area of …………… there is a deep carious cavity with softened pigmented dentin, probing is painful in the area of the bottom of the carious cavity, the reaction to thermal stimulation is positive and passes quickly.

Chronic pulpitis

complaints : for the presence of a carious cavity in the area of ……………, pain from thermal irritants and when food gets into the carious cavity.

Sf/1os.: In the area of …………… there is a deep carious cavity filled with softened pigmented dentin, probing is painful in the area of the bottom of the carious cavity. Probing revealed an exposed pulp horn. The reaction to thermal stimuli is positive.

Exacerbation of chronic pulpitis

complaints : for spontaneous paroxysmal, night pain with irradiation to the area ……………. From the anamnesis: previously there were pains of a spontaneous nature.

Sf/1os.: .: In the area …………… there is a deep carious cavity communicating with the tooth cavity. probing is sharply painful. The reaction to thermal stimuli is positive, the color of the tooth is not changed.

Chronic fibrous periodontitis is noted

complaints : for the presence of a deep carious cavity in the area…………… From the anamnesis: occasionally it is characterized by slight pain when biting.

Sf/1os.: In the area…………… there is a deep carious cavity communicating with the tooth cavity. probing the entrance to the cavity is painless, percussion is painless. the tooth is discolored. On Rg: widening of the periodontal fissure in the area of the root apex.

Chronic granulomatous periodontitis

complaints : for the presence of a deep carious cavity in the area …………… Change in tooth color. From the anamnesis: occasionally there is sensitivity in the jaw and slight pain when biting.

Sf/1os.: In the area: …………… deep carious cavity communicating with the tooth cavity. Probing the entrance to the cavity is not painful. On palpation on the gum c

There is a painful desiccation of the vestibular surface. Percussion lightly

painful. On Rg: in the area of the root apex there are clearly defined, round-shaped bone tissue depressions of size …….

Chronic granulating periodontitis

complaints : for the presence of a deep carious cavity in the area of ……………. The history shows occasional pain when biting, periodic formation of a fistula in the area……..

Sf/1os.: In the area……………a deep carious cavity communicating with the tooth cavity. The tooth is discolored. Probing is painless. Percussion is slightly painful. On the mucous membrane in the area………… there is a fistulous tract with purulent compartments. On Rg: in the area of the root apex there is a focus of destruction of bone tissue with corroded contours.

Exacerbation of chronic periodontitis

complaints : for aching pain in the area……………Sharp pain when biting on a tooth.

Sf/1os.: .: In the area …………… there is a deep carious cavity communicating with the tooth cavity. probing is painless. Percussion is sharply painful. Mucous in

area…………… hyperemic, slightly swollen. Rg according to the form.

An example of the treatment of average caries template for a dentist

Date of_______________

Complaints: no, for quickly passing pain when eating sweet, cold food in the _______ tooth, I contacted him for the purpose of sanitation.

Anamnesis: ____the tooth was not previously treated, was previously treated for caries, the filling fell out (partially), I noticed the cavity on my own, during an examination _____ days (week, month) ago, I did not seek help.

Objectively: the facial configuration is not changed, the skin is clean, regional lymph nodes are not enlarged. The mouth opens freely. The mucous membrane of the oral cavity is pale pink and moist. On the medial, distal, vestibular, oral, chewing surface(s)______ of the tooth, a carious cavity of medium depth, filled (partially filled) with softened pigmented dentin, filling material. Probing is painful along the enamel-dentin border, percussion is painless, the reaction to temperature stimuli is painful and passes quickly. GI=___________.

D.S. : Average caries of _______ tooth. Black class _________.

Treatment: Psychological preparation for treatment. Under anesthesia, without anesthesia, preparation of a carious cavity (removal of a filling), medicinal treatment with a 3.25% sodium hypochlorite solution, rinsing, drying._______________________ Isolating pad ________________Filling______________________. Grinding. Polishing.

Seal insulation: Vaseline, Axil, varnish.

At 01 069 06
A 12 07 003
A 16 07

Doctor:____________

Turnout________ .

Medical records in dentistry and rules for maintaining them.

4.1.Medical record of a dental patient

(registration form No. 043/у)

The medical record of a dental patient is filled out when the patient first visits the clinic: passport data - by a nurse in the primary medical examination room or by a registrar.

The diagnosis and all subsequent sections of the card are filled out directly by the attending physician of the relevant profile.

In the “diagnosis” line on the title page of the card, the attending physician makes a final diagnosis after completing the examination of the patient, performing the necessary clinical and laboratory tests and analyzing them. Subsequent clarification of the diagnosis, expansion or even change of it is allowed, with the obligatory indication of the date. The diagnosis must be detailed, descriptive and only based on diseases of the teeth and oral cavity.

Under the dental formula, additional data is entered regarding the teeth, bone tissue of the alveolar processes (changes in their shape, position, etc., etc.), bite.

The “laboratory tests” section includes the results of additional necessary studies carried out according to indications to clarify the diagnosis.

Records of repeated visits by a patient with a given disease, as well as in the case of visits with new diseases, are made in the card diary.

It ends with an “epicrisis” (a brief description of the treatment results) and practical recommendations (instructions) proposed by the attending physician.

In a dental clinic, department or office, only one medical record is created per patient, in which records are made by all dentists to whom the patient has consulted. When contacting another specialist, for example, an orthopedic dentist or orthodontist, it may be necessary to make changes to the diagnosis, additions to the dental formula, to the description of the dental status, general somatic data, as well as to record all stages of treatment with their own independent outcome and instructions. For this purpose, you need to take the insert with the same card number written in and attach it to the previously established one.

When making repeated visits to specialists of any profile, after a year or two, you must again take the insert (the first sheet of the medical record), reflecting the entire status in it. Comparison of these data with previous ones will allow us to draw a conclusion about the dynamics or stabilization of pathological conditions.

The medical record of a dental patient, as a legal document, is kept in the registry for 5 years after the last visit to the patient, after which it is archived.

Medical record No. 043/u contains three main sections.

The first section is the passport part. It includes:

card number; date of issue; last name, first name and patronymic of the patient; age of the patient; gender of the patient; address (place of registration and place of permanent residence); profession;

diagnosis at initial visit;

information about past and concomitant diseases;

information about the development of the present (which became the reason for the initial treatment) disease.

This section can be supplemented with passport data (series, number, date and place of issue) for persons over 14 years of age, and birth certificate data for persons under 14 years of age.

The second section is data from objective research. He contains:

external inspection data;

oral examination data and a table of dental condition, filled out using officially accepted abbreviations (absent - O, root - R, caries - C, pulpitis - P, periodontitis - Pt, filled - P, periodontal disease - A, mobility - I, II, III (degree), crown - K, artificial tooth - I);

description of bite;

description of the condition of the oral mucosa, gums, alveolar processes and palate;

X-ray and laboratory data.

The third section is the general part. It consists of:

examination plan;

treatment plan;

treatment features;

records of consultations, consultations;

clarified formulations of clinical diagnoses, etc.

The information contained in the patient’s medical record has significant legal significance for clarifying the circumstances of the provision of dental services and assessing their quality. Therefore, the entries made in the medical record represent valuable information that can serve as one of the main evidence in cases involving the provision of medical care. Despite the obvious legal significance of primary medical documents, many doctors are negligent in maintaining outpatient records, which subsequently often leads to various organizational and clinical problems. Typical mistakes made when maintaining outpatient records in dental practice include the following:

careless filling out of the passport part, as a result of which it is difficult to find the patient in the future to invite him for a re-examination to study long-term results;
unacceptable brevity, the use of unacceptable abbreviations in records, which can cause various errors, including the provision of inadequate assistance;
untimely recording of medical interventions performed (some doctors record medical interventions not on the day they are performed, but on the days of subsequent visits), which can lead to additional errors, especially when the patient is seen by another doctor who finds it difficult to understand the volume from the outpatient card and the nature of assistance at previous stages of treatment; for this reason, unnecessary (and even erroneous) manipulations are sometimes carried out;
failure to include the results of the patient’s examination (tests, X-ray data, etc.) in the outpatient card, which is why it is necessary to repeatedly subject him to unnecessary - and, moreover, not always pleasant - manipulations;
the dental formula, which is the main source of information about the patient’s dental status, is not filled out;
information about previous interventions regarding the diseased tooth is not reflected;
the treatment methods used are not justified;
the moment of completion of treatment is not recorded;
information about complications that arise during certain treatment methods is not reflected;
corrections, deletions, erasures, and additions are allowed, and this is usually done when the patient has complications or comes into conflict with the doctor.

OKUD form code ___________

OKPO institution code ______
Medical documentation

Form No. 043/у

Approved by the USSR Ministry of Health

04.10.80 No. 1030

name of institution
MEDICAL CARD

dental patient

№ _____________ 19... ____________
Full Name ________________________________________________________

Gender (M., F.) ______________________ Age ___________________________________

Address _________________________________________________________________________

Profession _____________________________________________________________________

Diagnosis ________________________________________________________________________________

Complaints ______________________________________________________________________________

Previous and concomitant diseases _____________________________________________

_______________________________________________________________________________

Development of the present disease ________________________________________________

_______________________________________________________________________________

For the printing house!

when preparing a document

A5 format
Page 2 f. No. 043/у
Objective research data, external examination ______________________________

_______________________________________________________________________________

Examination of the oral cavity. Dental condition
Legend: none -
- 0, root - R, Caries - C,
Pulpitis - P, periodontitis - Pt,	8	7	6	5	4	3	2	1	1	2	3	4	5	6	7	8
sealed - P,
Periodontal disease - A, mobility - I, II
III (degree), crown - K,
art tooth - I

_______________________________________________________________________________

Bite __________________________________________________________________________

Condition of the oral mucosa, gums, alveolar processes and palate

_______________________________________________________________________________

X-ray and laboratory data ______________________________

_______________________________________________________________________________

_______________________________________________________________________________
Page 3 f. No. 043/у

date	DIARY with repeated diseases	Last name of the attending physician

Treatment results (epicrisis) ___________________________________________________

_______________________________________________________________________________

Instructions ___________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________
Attending physician _______________ Head of department _____________________
Page 4 f. No. 043/у
Treatment _______________________________________________________________________

_______________________________________________________________________________

date	DIARY anamnesis, status, diagnosis and treatment upon presentation with repeated diseases	Last name of the attending physician

Page 5 f. No. 043/у

Survey plan	Treatment plan	Consultations

etc. to the end of the page

4.2. Dentist daily record sheet

(registration form No. 037 /у)

The “Daily record sheet for the work of a dentist (dentist) of a dental clinic, department, office” is filled out daily by dentists and dentists conducting outpatient therapeutic, surgical and mixed appointments in medical institutions of all types providing dental care to adults and adolescents and children.

The “sheet” is used to record the work carried out by dentists and dentists in one day.

Based on the data from the “Sheet”, the “Summary Statement” is filled out. Control over the correct completion of the “Sheet” and the translation of its data into the “Summary Statement” is carried out by the manager to whom the doctor is directly subordinate.

When monitoring the correctness of the “Leaflet”, the manager compares the diary entries with the medical record of the dental patient (form N 043/u).

The doctor can also check the correctness of work accounting (volume of work, number of units of labor input, etc.) by comparing the entries in the “Sheet” with the data in the “Summary Statement”.
4.3. Summary record of the work of a dentist (dentist) of a dental clinic, department, office

(registration form No. 039-2/у-88)

The “summary statement” is compiled by a medical statistician or an employee designated by the head of the institution. The “Summary Statement” is filled out daily based on the development according to the data from the “Sheet” of the doctor’s work (form N 037/u-88). At the end of the month, each doctor’s “Summary Statement” summarizes the results. Based on the data from the “Summary Statements” obtained based on the results of the work of all dental doctors for 12 months, the table is filled out. 7 of reporting form No. 1.

After filling out the “Summary Statement” for all days of the month, the total for each column is summed up.

In dental clinics, departments, offices that provide care only to adults or only to children, data on the doctor’s work is filled out in one “Summary Statement”, because in these cases, the need to differentiate between adults and children is eliminated.

In dental clinics, departments, and offices that provide care to both adults and children, two “Summary Statements” are kept for each doctor. One statement records general data, the other records data about children.
4.4. Logbook for preventive oral examinations

(registration form No. 049-u)

The journal serves to register preventive examinations of the oral cavity of all age professional groups of the population, mainly those on maternity leave, dispensary groups, as well as the organized children's population (preschoolers and schoolchildren). It is the main accounting document in which the preventive work carried out by dentists and dentists among the population is recorded.

The log is filled out in medical institutions of all profiles, including dental offices in schools and industrial enterprises, and health centers.

The working part of the journal consists of 7 columns, for each line against the surname of the person examined, healthy persons who do not need sanitization and those previously sanitized are marked with symbols (the word “yes” or the sign “+”).

The column “needs sanitation” indicates the amount of work to be done, for which a dental formula and symbols are used. In the “sanitized” column, persons are noted who have completely completed sanitization, indicating the number of fillings applied (it must be no less than the number of affected teeth shown in the previous column).

Based on the entries in the journal, the corresponding columns f. No. 039-2/u “Diary of a dentist’s work.”

4.5. Daily record sheet for the work of an orthopedic dentist

(registration form No. 037-1/у)

The daily record sheet for the work of an orthopedic dentist is the main primary document, reflecting the workload of one working day with the number of patients and the volume of treatment and preventive measures.

Used to fill out a diary for recording the work of an orthopedic dentist (form No. 039-4/u).

To obtain summary data for a working day, the information from the sheet at the end of the working day is entered by the doctor into the diary (accounting form No. 039-4/u) of the corresponding calendar date or month.

To be completed in all budgetary and self-supporting dental orthopedic institutions (departments).

4.6. Diary of the work of an orthopedic dentist

(registration form No. 039-4/у)

The diary is intended to record the treatment and preventive work of an orthopedic dentist for one working day and in total for a month.

The main primary medical document used to fill out the diary columns is the Daily Record Sheet for the work of an orthopedic dentist (form No. 037-1/u).

4.7. Medical record of an orthodontic patient

(registration form N 043-1/у)

Registration form N 043-1/у “Medical card of an orthodontic patient” (hereinafter referred to as the Card) is filled out by a doctor of a medical organization (other organization) providing medical care on an outpatient basis.

The card is filled out for each patient who applies for the first time.

The title page of the Card is filled out at the registry of the medical organization upon the patient’s first request. The title page of the Card indicates the data of the medical organization in accordance with the constituent documents, and indicates the Card number - the individual Card registration number established by the medical organization.

The Map notes the nature of the course of the disease, diagnostic and therapeutic measures carried out by the attending physician, recorded in their sequence.

The card is filled out for each patient visit.

Entries are made in Russian, accurately, without abbreviations, all necessary corrections in the Card are made immediately, confirmed by the signature of the doctor filling out the Card. It is allowed to write the names of drugs for medical use in Latin.
4.8. Diary of the work of an orthodontist

(registration form No. 039-3/у)

The diary is intended to record the work of a dentist-orthodontist conducting outpatient visits in budgetary and self-supporting institutions serving adults and children.

The diary is filled out daily by each orthodontist based on the entries in the medical record of the dental patient f. No. 043/у and is used to obtain data for the day and in total for the month of work.