Algorithm for preparing a “medical record for a dental patient.” IV. samples of filling out a dental patient's medical record for the treatment of major dental diseases Filling out a dental record for the treatment of periodontitis sample

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

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

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

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

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

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

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

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

Medical card 043 y is the property of the clinic.

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

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

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

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

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

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

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

Dental patient medical record form

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

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

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

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

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

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

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

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

You might be interested

• Checking a patient's complaint against a dental clinic

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

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

• you gave recommendations
• these recommendations were not implemented.

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

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

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

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

Storage periods for a dental patient's medical record

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

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

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

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

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.

A dental patient's medical record is a document used to identify the patient. The medical record describes the characteristics of the condition and changes in its health.

All medical record data is filled out by a doctor and confirmed by instrumental, laboratory and hardware research data. In addition, the medical record reflects all the features and stages of treatment.

For each dental patient, several documents are drawn up, which include informed voluntary consent for dental treatment, consent to the processing of personal data and a medical record of the dental patient.

We were told about the rules for their registration at the RaTiKa dental clinic (Ekaterinburg).

Medical record of a dental patient

Back on October 4, 1980, by Order of the USSR Ministry of Health No. 1030, form 043/u was approved, which was intended specifically for maintaining records of dental patients.

Dentists were obliged to strictly adhere to this form, but already in 1988 the above order was canceled. Since then, no law has been issued that would order dentists to use a specific form of medical record. However, on November 30, 2009, the Ministry of Health and Social Development of the Russian Federation issued a letter in which it recommended that doctors use the old forms to keep records of their activities (for dentists - 043/u).

Current legislation recommends (but does not oblige) the use of form 043/у for medical records of dental patients. However, it is most convenient to maintain patient records in the appropriate dental management programs.

Most clinics do use this form, but often transform it slightly to a more convenient format, for example, instead of A5 they print in A4 format or make other minor changes.

A dental patient's medical record is completed upon the patient's first visit to the dental clinic. Personal information (full name, gender, age, etc.) is filled out by a nurse or dental administrator, and the rest of the card is filled out exclusively by the attending physician.

Rules for drawing up a medical card for a dental patient by a doctor

1. The card contains information about the patient’s diagnosis and complaints.
2. The diagnosis is entered into the chart after the examination.
3. It is possible to clarify the diagnosis or completely change it. When making amendments, the date must be indicated.
4. It is important to note the presence of concomitant diseases of the patient or those significant for dental procedures, diseases that he has already suffered.
5. It is necessary to describe how the current disease develops, include data obtained during an objective study, information about the bite, the condition of the mucous membrane, oral cavity, gums, alveolar processes, and palate.
6. X-rays and laboratory tests must also be included in the dental patient’s chart.

Each of them should write down their treatment steps on a separate insert and then place them on the chart.

Rules for storing medical records

• The medical card must be kept at all times; it is not given to the patient at home. But we recommend that you give the patient a special form that indicates the date of the next visit. You can develop and release it yourself or use one offered by partner companies, for example, a toothpaste manufacturer.
• Considered a legal document, the card must be stored for 5 years from the day when the patient last visited the dentist and a corresponding entry was made about this in the card. The document is then transferred to the archive.
• The content of medical records should prevent the possibility of violation of confidentiality and illegal access to them, so it is best to keep them under lock and key.

Informed voluntary consent to dental treatment

Dental services belong to the “List of certain types of medical interventions to which citizens give informed voluntary consent when choosing a doctor and medical organization to receive primary health care,” which was approved on April 23, 2012 by the Ministry of Health and Social Development of the Russian Federation. By signing this document, the patient indicates that he is voluntarily undergoing dental treatment; the need for certain procedures, the plan of which is prescribed in his medical record, was explained in detail to him. The client demonstrates an understanding of possible outcomes, existing risks, and alternative treatment pathways. He knows about the possible accompanying effects of the planned treatment (pain, discomfort, swelling of the face, sensitivity to cold/heat, etc.). The patient also confirms his understanding that the treatment plan may change during the process.

The document can be signed by the patient himself or an authorized representative (if there is a document that confirms the right to represent his interests).

Consent to the processing of personal data

This document gives the organization the right to process the patient’s personal data (full name, date of birth, type of identification document, etc.) in accordance with existing legislation. If the patient is a minor, then consent to the processing of personal data is signed by parents or legal representatives.

All materials are provided by the RaTiKa dental clinic (Ekaterinburg). Text: Elizaveta Gertner

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

No. _____________ 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 ______________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Bite __________________________________________________________________________

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

_______________________________________________________________________________

_______________________________________________________________________________

X-ray and laboratory data ______________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Page 3 f. No. 043/у

Treatment results (epicrisis) ___________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Instructions ___________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Attending physician _______________ Head of department _____________________

Page 4 f. No. 043/у

Treatment _______________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Page 5 f. No. 043/у

etc. to the end of the page