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 doctor 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.

OPTIONS FOR RECORDING THE ILLNESS HISTORY OF PATIENTS WHO ARE SUGGESTED TOOTH EXTRACTION AND OTHER SURGICAL MANIPULATIONS

Exacerbation of chronic periodontitis

Example 1.

Complaints of pain in the upper jaw on the left, pain at 27 when biting.

History of the disease. 27 was previously treated, periodically bothered. Two days ago, 27 fell ill again, pain appeared in the area of the upper jaw on the left, the pain when biting on 27 increases. History of influenza.

Local changes. There is no change during external examination. The submandibular lymph nodes are slightly enlarged on the left, painless on palpation. The mouth opens freely. In the oral cavity: 27 under a filling, the color is changed, its percussion is painful. In the area of the apex of roots 27, a slight swelling of the mucous membrane of the gums on the vestibular side is detected; palpation of this area is slightly painful. On X-ray 27, the palatal root is sealed to the apex, the buccal roots are sealed to 1/2 of their length. At the apex of the anterior buccal root there is a loss of bone tissue with unclear contours.

Diagnosis: “exacerbation of chronic periodontitis of the 27th tooth.”

A) Under tuberal and palatal anesthesia with 2% novocaine solution - 5 mm or 1% trimecanne solution - 5 mm plus 0.1% adrenaline hydrochloride - 2 drops (or without it), extraction was performed (specify tooth), socket curettage ; the hole filled with a blood clot.

B) Under infiltration and palatal anesthesia (anaesthetics, see the entry above, indicate the presence of adrenaline), removal (18, 17, 16, 26, 27, 28) was performed, curettage of the hole; the hole filled with a blood clot.

B) Under infiltration and palatal anesthesia (anaesthetics, see the entry above, indicate the presence of adrenaline), removal was performed (15, 14, 24, 25). Curettage of the socket(s), the socket(s) became filled with blood clot(s).

D) Under infraorbital and palatal anesthesia (see anesthetics above, indicate the presence of adrenaline), removal was performed ( 15, 14, 24, 25).

E) Under infiltration and incisive anesthesia (see anesthetics above, indicate the presence of adrenaline), removal was performed (13, 12, 11, 21, 22, 23) . Curettage of the hole, it is compressed and filled with a blood clot.

E) Under infraorbital and incisal anesthesia (see anesthetics above, indicate the presence of adrenaline), removal was performed (13, 12, 11, 21, 22, 23). Curettage of the hole, it is compressed and filled with a blood clot.
^

Acute purulent periodontitis

Example 2.

Complaints of pain in the area of 32, radiating to the ear, pain when biting on 32, a feeling of an “overgrown” tooth. General condition is satisfactory; past diseases: pneumonia, childhood infections.

History of the disease. About a year ago, pain first appeared at 32, and was especially bothersome at night. The patient did not see a doctor; gradually the pain subsided. About 32 days ago the pain reappeared; consulted a doctor.

Local changes. There are no changes upon external examination. The submental lymph nodes are slightly enlarged and painless on palpation. The mouth opens freely. In the oral cavity 32 - there is a deep carious cavity communicating with the tooth cavity, it is mobile, percussion is painful. The mucous membrane of the gums in area 32 is slightly hyperemic and swollen. There are no changes on X-ray 32.

Diagnosis: “acute purulent periodontitis 32.”

A) Under mandibular and infiltration anesthesia (see anesthetics above, indicate the presence of adrenaline), removal of (specify tooth) 48, 47, 46, 45, 44, 43, 33, 34, 35, 36, 37, 38 was performed; curettage of the holes, they are compressed and filled with blood clots.

B) Under torusal anesthesia (see anesthetics above, indicate the presence of adrenaline), 48, 47, 46, 45, 44, 43, 33, 34, 35, 36, 37, 38 were removed.

Curettage of the hole, it is compressed and filled with a blood clot.

C) Under bilateral mandibular anesthesia (see anesthetics above), 42, 41, 31, 32 were removed. Curettage of the hole, it was compressed and filled with a blood clot.

D) Under infiltration anesthesia (see anesthetics above, indicate the presence of adrenaline), 43, 42, 41, 31, 32, 33 were removed. Curettage of the hole, it was compressed and filled with a blood clot.

Acute purulent periostitis

Example 3.

Complaints of swelling of the right cheek, pain in this area, increased body temperature.

Previous and concomitant diseases: duodenal ulcer, colitis.

History of the disease. Five days ago pain appeared at 13; two days later, swelling appeared in the gum area, and then in the cheek area. The patient did not consult a doctor; he applied a heating pad to his cheek, took warm intraoral soda baths, and took analgia, but the pain grew, the swelling increased, and the patient consulted a doctor.

Local changes. An external examination reveals a violation of the facial configuration due to swelling in the buccal and infraorbital areas on the right. The skin over it is not changed in color, it folds painlessly. The submandibular lymph nodes on the right are enlarged, compacted, and slightly painful on palpation. The mouth opens freely. In the oral cavity: 13 - the crown is destroyed, its percussion is moderately painful, mobility is II – III degrees. Pus is released from under the gingival margin. The transitional fold in the area 14, 13, 12 bulges significantly, is painful on palpation, and fluctuation is detected.

Diagnosis: “acute purulent periostitis of the upper jaw on the right in the area of 14, 13, 12 teeth”

Example 4.

Complaints of swelling of the lower lip and chin, spreading to the upper submental area; sharp pain in the anterior part of the lower jaw, general weakness, lack of appetite; body temperature 37.6 ºС.

History of the disease. After hypothermia a week ago, spontaneous pain appeared in the previously treated 41, pain when biting. On the third day from the onset of the disease, the pain in the tooth decreased significantly, but swelling of the soft tissues of the lower lip appeared, which gradually increased. The patient did not undergo treatment; he went to the clinic on the 4th day of the disease.

Previous and concomitant diseases: influenza, sore throat, penicillin intolerance.

Local changes. During an external examination, swelling of the lower lip and chin is determined; its soft tissues are not changed in color and are folded freely. The submental lymph nodes are slightly enlarged and slightly painful on palpation. Opening the mouth is not difficult. In the oral cavity: the transitional fold in the area of 42, 41, 31, 32, 33 is smoothed, its mucous membrane is swollen and hyperemic. Palpation reveals a painful infiltrate in this area and a positive symptom of fluctuation. Crown 41 is partially destroyed, percussion is slightly painful, mobility is grade I. Percussion of 42, 41, 31, 32, 33 is painless.

Diagnosis: “acute purulent periostitis of the lower jaw in the area of 42, 41, 31, 32.”

^ Record of surgical intervention for acute purulent periostitis of the jaws

Under infiltration (or conduction - in this case, specify which one) anesthesia (see the anesthetic above, indicate the presence of adrenaline), an incision was made along the transitional fold in the area

18 17 16 15 14 13 12 11|21 22 23 24 25 26 27 28

48 47 46 45 44 43 42 41| 31 32 33 34 35 36 37 38

(specify within which teeth) 3 cm (2 cm) long to the bone. Pus was obtained. The wound was drained with a rubber strip. Prescribed (indicate medications prescribed to the patient and their dosage).

The patient is incapacitated from _______ to _________, sick leave No. ______ has been issued. Appearance ______for dressing.

Diary entry after opening a subperiosteal abscess in acute purulent periostitis of the jaw

The patient's condition is satisfactory. There is an improvement (or worsening, or no change). The pain in the jaw area has decreased (or increased, remains the same). The swelling of the perimaxillary tissues has decreased, and a small amount of pus is released from the wound in the oral cavity. The wound along the transitional fold of the jaw was washed with a 3% solution of hydrogen peroxide and a solution of furatsilin at a dilution of 1:5000. A rubber strip is inserted into the wound (or the wound is drained with a rubber strip)

Example 5.

Complaints of pain in the area of the hard palate on the left of a pulsating nature and the presence of swelling on the hard palate. The pain intensifies when touching the swelling with the tongue.

History of the disease. Three days ago, pain appeared in the previously treated 24, pain when biting, and a feeling of an “overgrown tooth.” Then the pain in the tooth decreased, but a painful swelling appeared on the hard palate, which gradually increased in size.

Past and concomitant diseases: stage II hypertension, cardiosclerosis.

Local changes. Upon external examination, the configuration of the face was not changed. Palpation reveals an increase in the submandibular lymph nodes on the left, which are painless. Mouth opening freely. In the oral cavity: on the hard palate on the left, respectively 23 24 there is an opal-shaped bulge with fairly clear boundaries, the mucous membrane above it is sharply hyperemic. At its center there is a fluctuation. 24 - the crown is partially destroyed, there is a deep carious cavity. Percussion of the tooth is painful, tooth mobility is grade I.

Diagnosis: “acute purulent periostitis of the upper jaw on the palatal side to the left (palatal abscess) from the 24th tooth.”

Under palatal and incisal anesthesia (specify the anesthetic and the addition of adrenaline), the abscess of the hard palate was opened with excision of soft tissue to the bone in the form of a triangular flap within the entire infiltrate, and pus was obtained. The wound was drained with a rubber strip. Drug therapy was prescribed (specify which).

The patient is incapacitated from _______ to _______., sick leave No. _______ was issued. Show up _________for dressing.

Medical record of a dental patient
No. April 27, 2002
Last name, first name, patronymic: Ivanov Ivan Ivanovich Gender male. Address Moscow. Age: 10/01/1966
Contact numbers: 452-17-73 Profession: teacher. Diagnosis: 1 1 Average caries Complaints about the presence of a cavity, food ingestion, pain from temperature stimuli (indicate a change in tooth color, aesthetic defect). Previous and concomitant diseases: considers himself healthy, or: concomitant somatic cytology (hypertension, allergic reactions, head injuries, heart disease, lung disease, hepatitis, venereal disease)

Examination of the oral cavity. Condition of teeth. Legend: none -
O, root - ?, caries - C, pulpitis - R, periodontitis-filled - P, periodontosis - A, mobility - I, II, III (degree), crown - K, claim. tooth - I

Medical record of a dental patient: rules for registration and storage. Medical card Registration of dental cards

Medical record of a dental patient

Such a document contains all the necessary information about the patient, the condition of his teeth, bite, treatment methods, types of diseases, just like a medical record. X-ray readings are also included in the card.

This is a special new document. Every dental clinic must issue such a card for each patient. The administrator fills in the client’s personal data, and the dentist makes the appropriate entries in the card itself.

Dental patient medical record form

The legislation of the Russian Federation has established a specific form 043u for a dental patient’s card. All other types of records are considered unofficial and have no legal force.

Extract from the medical record of a dental patient

To obtain such an extract, you will need to visit a dental clinic, write an application, and fill out a request. Then it will take time to complete the document. What if you need an extract urgently? No time to wait? We are ready to help you.

From us you can buy an extract from a medical record, a medical record of an inpatient. We will do this quickly, the document will be genuine, and you will be able to present it to any institution.

Buy a dental patient's medical card

We offer to buy a dental patient card. Such a card will have all degrees of protection, signed by real doctors. It can be presented to any medical institution. If you have this type of card, you will be able to continue the treatment you started earlier.

Filling out a medical record for a dental patient

Only a medical institution providing dental services has the right to fill out such a document. The front side of the card is drawn up by the administrator, all subsequent entries are made by doctors. Each note must be written legibly and confirmed by the signature and seal of the doctor.

Medical record of a dental patient 2015

This year, only cards that meet sample 043u can be officially used. All other options have no legal force. For each patient, a dental medical record, form 043u, must be created.

New medical record for a dental patient

There are unforeseen situations in life when a certain document is urgently required. For example, a medical record of a dental patient, sick leave. We offer to produce an authentic document for any person. This service is provided promptly; the prepared document will be delivered by courier and handed over personally.

Medical card of a dental patient in Moscow

From us you can order a medical record for a dental patient. You can submit your application by phone, email, or come to us. We will independently issue a medical card for a dental patient, form 043u. When the document is issued, executed and approved by current doctors, our administrator will call you back. We ourselves organize delivery in Moscow, you choose any convenient place.

Buy certificate 043у

A child going to camp will need such a certificate 043u, and he will also need a certificate for the camp (form 079/u). In order to receive it, you and your child will need to visit the dentist. But is it worth it to injure the baby?

We offer to buy certificate 043у very inexpensively. You need to call us and place an order. On the same day, the courier will deliver the document to the location you specify.

Our team consists of experienced dentists who are always ready to help you. Therefore, the medical records, extracts and certificates we have prepared are real, certified by the seals and signatures of existing doctors. You can safely present them to any government agency.

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.



8	7	6	5	4	3	2	1	1	2	3	4	5	6	7	8

mild diseases, etc.: acute conditions at the time of treatment!
Development of the present disease: went to the clinic, indicate: for advice on sanitation of the oral cavity, in connection with the appearance of a cavity, in connection with the emerging aesthetic defect, painful sensations.
Objective research data, external examination
The configuration of the line is not changed, or is changed due to swelling of the soft tissues in the area (specify). The skin over the swelling is not changed in color (changed). folds easily 1does not fold). Lymph nodes are not palpable; palpable). 1-3 increased to 0.5 cm in diameter, mobile, soft elastic consistency (dense and immobile)
Dental deposits, their location and quantity:
Bite (specify what kind) orthognathic
Condition of the mucous membrane of the oral cavity, gums, alveolar processes and palate: Pale pink, moderately moisturized, or: hyperemic (with a bluish tint) and swollen in the area of all teeth or a group of teeth. bleeds when touched.

X-ray laboratory data Date (day, month, year).
On visiogram 11 there is a defect in the coronal part 11, in the area of the medial angle. The ratio of the carious cavity to the tooth cavity, the condition of the periodontal gap; osteoporosis or osteoporosis of the bone tissue surrounding the causative tooth, the presence of areas of bone tissue close in density to the tooth tissue, the presence of cavities or other formations in the part being examined.
Dear patient!
General diseases can affect the treatment process at the dentist, so we ask you to carefully fill out this form.
We guarantee that the information you provide in the questionnaire will be used only to select treatment based on your health and will not be available to third parties.
“*- QUESTIONNAIRE (filled out by the patient)
I report the following about my health status:
Last visit to the dentist
(indicate month and year.)
Not really

Allergies (drug, food, others)

Symptoms
What stops an attack?

Blood type_Rh factor
Do you suffer from diseases:

heart (angina, palpitations, shortness of breath)
kidney
liver
gastrointestinal tract
lungs (bronchial asthma)

Do you suffer from:

high blood pressure
low blood pressure

Do you have seizures, fainting, or dizziness?
Prolonged bleeding after cuts
Diabetes
Pregnancy
Medications taken (specify)
Have you ever had a head injury?
Past hepatitis
AIDS, sexually transmitted diseases
Recurrent oral ulcers, herpes
Bruxism (night grinding of teeth)
Diseases of the maxillary sinuses
Do you use drugs?
Do you smoke

19.
I sincerely answered all points of the questionnaire, I would like to additionally inform you about the state of my health as follows:
I know that only in the case of mandatory preventive examinations (once every 6 months) can the results of treatment and prosthetics be calculated for a certain period of time.
I know that if I take medications before visiting the dentist, I must inform the doctor about this.
" " 200_ year Patient's signature
AGREEMENT FOR PROVISION OF DENTAL SERVICES No.
Option A. Survey agreement
" " 200_ g.
We, the undersigned, are referred to as
hereinafter CONTRACTOR, represented by the General Director
, acting on the basis of the Charter,
license No. from "_" 200_g. for the provision of medical services
Decrees of the Government of the Russian Federation of January 13, 1996. No. 27 with one
sides, and

The contractor undertakes to instruct a doctor.

(Full name of doctor)

Carry out an interview and examination of the CUSTOMER at the time agreed upon with the CUSTOMER to establish a preliminary diagnosis, the scope of necessary treatment and comprehensively inform the CUSTOMER about the results of the examination, reflecting the preliminary diagnosis and treatment plan in the CUSTOMER’s outpatient record. In the outpatient clinic
On the chart, the CUSTOMER makes a written note about familiarization with the preliminary diagnosis, treatment plan and possible complications.
The CUSTOMER undertakes to pay the cost of the actions provided for in clause 1.1 of this agreement at the prices of the price list, which the CUSTOMER has previously read.
The CUSTOMER agrees that during the preliminary review it may be necessary to carry out additional (special)

cialized) research methods, by carrying out radiographic and other necessary diagnostic measures, which are carried out by the CONTRACTOR for a fee. If the CONTRACTOR does not have the appropriate technical capabilities, the CONTRACTOR reserves the right to refer the CUSTOMER to another specialized medical organization.

Option B. Treatment agreement
" " 200 g.
We, the undersigned,
hereinafter referred to as the CONTRACTOR, represented by the General Director, the current
on the basis of the Charter, license No. dated " " 200 per oka
knowledge of medical services and Decree of the Government of the Russian Federation of January 13, 1996 No. 27 on the one hand, and,
hereinafter referred to as the CUSTOMER, on the other hand, have entered into this agreement as follows:

The CONTRACTOR undertakes:

In accordance with the preliminary diagnosis and treatment plan included in the CUSTOMER’s outpatient card (clause 1.1 of agreement No. /Aot 200_)
Doctor

(Full name of doctor)
who is obliged to provide high-quality and most painless treatment methods in accordance with medical indications, using painkillers if necessary.

In the event of an unexpected absence of the attending physician on the day appointed for treatment, the CONTRACTOR has the right to appoint another doctor to carry out the treatment.

The CUSTOMER undertakes:

follow all instructions of the attending physician and medical personnel.
Appear for treatment at the scheduled time, agreed with the doctor.
Maintain good oral hygiene and attend scheduled medical check-ups.
Pay for medical services according to the price list, which the CUSTOMER has read before concluding this agreement.

The CUSTOMER agrees that special types of treatment will be carried out by relevant specialists of the CONTRACTOR.
The CONTRACTOR is liable in the event of non-fulfillment or poor performance of its obligations in the presence of its fault.
In the event of a disagreement between the CONTRACTOR and the CUSTOMER regarding the quality of services provided, the dispute between the parties is considered by the chief physician (deputy chief physician) of the CONTRACTOR. If disagreements are not resolved, disputes are considered by clinical expert commissions and (or) experts from territorial organizations of the Dental Association (All-Russian) in the prescribed manner.
Other conditions for all types of dental services, except for periodontology, there is a 36-month guarantee, provided that the CUSTOMER regularly comes for a preventive examination with the CONTRACTOR at least once every 6 months.

CONTRACTOR CUSTOMER
(Patient's full name)

SAMPLE CARD MAINTENANCE

Abbreviations are not allowed in the outpatient card;
When a filling is found, it is indicated on what surface of the tooth it is located^;
When a cavity is formed, its Black class is indicated.

Average caries
Complaints: short-term pain from cold, sweet foods, the presence of a cavity. Indicate the tooth formula.
Objectively: on the (name) surface, (tooth formula) there is a carious cavity of medium depth, filled with softened, pigmented dentin. Probing is painful along the enamel-dentin border. Short-term pain from temperature stimuli. Percussion is negative.
Treatment: Under topical anesthesia, drug, concentration, dose and infiltration (conduction) anesthesia, drug, adrenaline concentration and dose, a cavity is formed according to the class (specify), the bottom is light, dense. The cavity was treated with medication (specify with what). On the (name) surface there is a description of the manipulations performed - filling, restoration, etc., with the name of the material and an indication of the color. Grinding, polishing.
Deep caries
Complaints: the presence of a carious cavity, food ingress, short-term pain from temperature stimuli in (specify the tooth formula).
Objectively: on the (name) surface of (specify the tooth formula) there is a deep carious cavity filled with softened dentin. Probing is slightly painful along the bottom of the carious cavity and along the enamel-dentin border. Rapid response to temperature stimuli. Percussion is negative.
Treatment: Under topical anesthesia, drug, concentration, dose and infiltration (conduction) anesthesia name, adrenaline concentration and dose, a cavity is formed and medicinally treated (specify with what) according to (specify) class. The bottom is light
(weakly pigmented), dense. Medical pad (name). Insulating gasket (name). On the (name) surface all the manipulations performed are described - filling, restoration, inlay, etc., with the name of the material and an indication of the color. Grinding, polishing.
The patient is warned about the possibility of pain and the need to denervate the tooth. ,
Patient's signature

X-ray analysis

Assessment of the crown part of the tooth (shape, contours, presence of carious cavities, their relationship to the tooth cavity);
Tooth cavity (presence, absence, shape, size, structure, presence of perforations);
Tooth root (number, size, shape, contours; fracture, perforation, degree of formation and resorption);
Root canal (presence, absence, width, obliteration, curvature, in the presence of filling material - degree of filling, foreign bodies);
Condition of the periodontium (expansion of the periodontal fissure, loss of bone tissue); f
Bone tissue of the alveolar processes of the jaws (destruction, osteoporosis, osteosclerosis);
Cortical plate (preserved, destroyed);
Interalveolar septa (character of contours, structure, changes in ridges).