Medical card. Medical record of a dental patient: rules for registration and storage Dental record 043 sample

Medical records in dentistry and rules for maintaining them.

4.1.Medical record of a dental patient

(registration form No. 043/у)

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.

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 ______________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Bite __________________________________________________________________________

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

_______________________________________________________________________________

_______________________________________________________________________________

X-ray and laboratory data ______________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________
Page 3 f. No. 043/у

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Instructions ___________________________________________________________________

_______________________________________________________________________________

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

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Page 5 f. No. 043/у

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.

Since the creation of the modern structure of dental care, the medical record of a dental patient has been its basic element. It existed when there was no trace of other documents, without which it is impossible to imagine the work of a modern clinic (contract, protocol of voluntary informed consent, insurance policy, etc.).

At the same time, many dental clinics completely or partially ignore the role of the dental patient’s medical record: they either do not use it at all, or they modernize, modify, or invent their own versions. And if the use of various variations on the theme of a dental patient’s medical record can be understood (in many ways, the existing form already lags behind the requirements of the time), then the complete absence of a medical record is completely unacceptable.

What is a dental patient's medical record?

A medical record of a dental patient is a document that properly identifies the patient and contains information characterizing the characteristics of the condition and changes in the state of his health, established by the doctor and confirmed by laboratory, instrumental and instrumental research, as well as the stages and features of the treatment.

Registration of a medical card for a dental patient –

The medical record of a dental patient is drawn up in accordance with orders of the USSR Ministry of Health No. 1030 of October 4, 1980 and No. 1338 of December 31, 1987. At the same time, the Ministries of Health of the USSR and the Russian Federation managed to create extreme confusion with the medical record. In 1988, an order of the USSR Ministry of Health was issued (No. 750 dated 10/05/1988), according to which the Order of the Ministry of Health No. 1030 became invalid. However, another, newer Ministry of Health, now the Russian Federation, since 1993 began to regularly refer to the provisions of Order No. 1030 of the USSR Ministry of Health, introducing appropriate changes and additions to it.

There are no later basic orders or other acts of the Russian Ministry of Health establishing the form of a medical record. Therefore, although many provisions of Order No. 1030 have lost force, new regulatory documents periodically contain references to those parts of the order that relate to the maintenance of medical records. In particular, the requirement remains that all medical institutions (note, regardless of their form of ownership) are required to maintain medical records in the established form. In dentistry, this is Form No. 043/у “Medical record of a dental patient.”

What does a medical card include?

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

1) First section– passport part. It includes:

• card number;
• date of its registration;
• last name, first name and patronymic of the patient;
• patient's age;
• patient's gender;
• 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.

2) Second section– objective research data. 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.

3) Third section- a common part. It consists of:

• examination plan;
• treatment plan;
• treatment features;
• records of consultations, consultations;
• clarified formulations of clinical diagnoses, etc.

Some features of the medical record

The material and type of medical record of a dental patient does not matter much. It can be produced in a clinical setting or by printing and, as a rule, is an A5 notebook. The main requirement is that it be in paper form and have records in the form approved by law. The passport part is prepared by a medical registrar, clinic administrator or nurse.

All other entries in the medical record are made only by the doctor, legibly, without corrections (a printed (computerized) option for making entries is possible), using only generally accepted abbreviations. The formulations of diagnoses, anatomical formations, names of instruments and medications are indicated in full, without abbreviations, taking into account the officially used terminology. The entry made is confirmed by the signature and personal seal of the doctor.

In addition to the records, the following must be included (pasted) in the medical record:

• test results (if any) - originals or copies;
• extracts from other medical institutions where dental care was provided, especially if the provision of dental care in other institutions occurred after the patient first applied (began to be observed) in this dental clinic;
• medical reports, expert opinions, consultations received in connection with the diseases for which the patient is observed in this clinic;
  medical reports, expert opinions, consultations received in connection with other diseases, the course of which may affect the characteristics of the dental disease;
• information on cancer examinations (based on the order of the Ministry of Health of the Russian Federation “On measures to improve the organization of cancer care for the population of the Russian Federation” No. 270 dated September 12, 1997);
• information on radiation doses received by the patient during X-ray examinations (based on the order of the Ministry of Health of the Russian Federation “On the introduction of state statistical monitoring of radiation doses of personnel and the population” No. 466 of December 31, 1999);
• X-rays of the patient’s teeth and maxillofacial area, taken in this dental clinic.

Let's take a closer look at the last point. Of the entire evidence base that is used by the parties when considering consumer claims in court in connection with the quality of services provided, X-ray images are of the greatest importance. Why? As an example, let’s look at a controversial situation that arises most often.

The patient had his teeth treated in several clinics and collected his x-rays from everywhere after the treatment was completed. At the same time, of course, in all clinics there were certain documents confirming the fact of treatment (service agreements, entries in the medical record, payment receipts, checks, etc.). In one of the clinics, an instrument broke off in a tooth canal during treatment. However, the patient sued not the clinic where the instrument was broken, but the richest of those where he was treated.

At the same time, it is almost impossible to prove the absence of fault of the clinic specified in the claim if the clinic cannot present an x-ray taken after completion of treatment. That is why the clinic is extremely interested in keeping all the images taken on the patient. However, certain legal difficulties arise here.

The fact is that radiography is usually included by clinics in the price list as a separate type of service. And on the basis of the Civil Code of the Russian Federation and the Law “On the Protection of Consumer Rights”, the patient has the right to regard the x-ray performed as a service paid for by him, the material expression (result) of which is an x-ray. Accordingly, the patient acquires the full right to take this image for himself.

Of course, this situation does not suit the clinic at all. Therefore, the clinic usually uses the following exit options:

1. include in the Contract for the provision of dental services a clause according to which x-rays taken in the clinic are an integral part of the medical record of the dental patient. In this case, all images taken at the clinic remain its property on the basis of an agreement concluded with the patient.
2. They give the patient not the image itself, but its image on paper or other media - for example, a copy from a visiograph, or a printout of a scanned image.

However, all of the above applies to the medical record of a dental patient, form No. 043/u. If a dental clinic uses its own form of medical records, then it may face serious problems in court proceedings. The fact is that the patient can submit a request for the clinic to provide evidence of a medical record of a dental patient in the form established by law (form No. 043/u).

In this case, the provision of a medical card of a different form by the dental clinic may be interpreted by the court as a formal basis for recognizing this form as not meeting the requirements of the law, and on this basis the card may not be accepted as written evidence. And this will allow you to ignore all the entries made in the card and give the patient grounds to accuse the clinic of improper record keeping.

Since this form of card is truly outdated and does not fully reflect both changes in civil legislation and new diagnostic and treatment standards, its certain modernization becomes inevitable. Therefore, in dentistry, as a way out of this situation, they use a loose leaf for the medical record (information sheet), taking into account the specific features of a particular clinic. It is much worse for a dental clinic if the dental patient’s medical record is not maintained at all.

FAQ -

1. Who makes entries in the medical record?
   The passport part is filled out by the registrar, administrator or nurse; all other entries are made only by the doctor.
2. How are entries entered into the medical record?
   Legibly, using only generally accepted abbreviations, without corrections, handwritten or printed, certified by signature and the doctor’s personal seal.
3. Why do you need a medical card?
   To reasonably protect the interests of the dental clinic, first of all, in court.
4. Can dentistry issue a medical card to a patient?
   Formally yes, in fact no.
5. What problems can there be for using the wrong card options?
   An incorrect version of the map may not be recognized by the court as written evidence, and the resulting lack of documentation required by law may become the reason for legal claims.
6. Does the patient have the right to collect x-rays?
   Yes, at least copies of photographs on paper or other media.
7. How do dentists update medical records?
   Use the medical record insert – information sheet.

^ CARIES IN THE SPOT STAGE or carious demineralization

The examination reveals a loss of the natural shine of the enamel in a limited area and a change in color to dull white (progressive demineralization).

INSPECTION:

examination, probing, staining of spots on enamel for the purpose of differential diagnosis with non-carious lesions.

^

The goal of treatment is to stabilize the carious process.

Cleaning the affected enamel surface with prophylactic paste "Radent";

Treatment of stains localized in areas that are not visible when smiling with the drug "Saforaid" (due to possible staining of teeth);

Treatment of spots localized in areas noticeable when smiling with the preparation "Stangard", fluoride varnish - "Komposil";

Treatment of affected areas of enamel with Stangard gel at home for 2 months.

1) disappearance of enamel stains

2) restoration of the shine of the enamel surface in the affected area.
^

II.SUPERFICIAL CARIES

INSPECTION:

inspection, probing, staining with a "Caries Detector".

^

Cleaning the surface of teeth using Radent paste;

Brown spots with a rough surface are subject to preparation and filling. In this case, filling materials are used: “Citrix”, “Cimex”, “AMSO”, “Lysix”, “Clearfil”.

Dentin protection - materials "Komposil", "Cimex", "Lika", "Clerafil Liner Bond 2V";

When filling with materials "Citrix", or "Clerafil AR-X", "Clerafil ST" - there is no need to apply a gasket and etching.

In case of superficial lesions in the area of ​​​​fnsur, it is necessary to treat the surface with the preparations “Saforaid”, “Komposil” and carry out dynamic monitoring during repeated examinations every 3 months.

If the dynamics are positive, seal the fissures with Titmate sealant.

Requirements for treatment results:

Absence of recurrent caries at the “tooth tissue - filling” interface;

Stabilization of the process in the fissure area.
^

III. MEDIUM CARIES

INSPECTION:

questioning, examination, instrumental examination (probing, percussion), electroodontodiagnosis, in unclear cases - x-ray examination for differential diagnosis with chronic periodontitis.

^ CHARACTERISTICS OF TREATMENT MEASURES:

Carrying out pain relief (filtration, conduction, etc.)

Cleaning the surface with Radent paste;

cavity preparation with removal of necrotic and pigmented tissues;

Application of the adhesive system (Clerafil Liner Bond 2V, Panavia F)

When filling with Citrix material, there is no need to apply a gasket or etching;

Application of filling material "Clerafil", "Lysix".

Requirements for treatment results:

Lack of hypersensitivity to temperature, mechanical and chemical stimuli;

^

IV. DEEP CARIES

INSPECTION:

questioning, examination, instrumental examination, electroodontodiagnosis, temperature test, differential diagnosis with moderate caries, with chronic forms of complicated caries.

^ CHARACTERISTICS OF TREATMENT MEASURES.

If there are difficulties in diagnosis, apply a diagnostic seal.

Carrying out pain relief

Removal of overhanging edges of enamel and softened dentin

Applying a therapeutic pad "Tsimex", "Lika", "Liner Bond".

Applying a temporary dressing with Cimex material.

Assessment of the quality of preparation with a "Caries Detector";

With a diagnosis of “Deep caries”:

Carrying out pain relief;

Carrying out preparation;

Checking the quality of preparation with a “Caries Detector”;

Application of a medical pad made of materials "Lika", "Cimex", "Liner Bond";

Application of insulating gasket "Tsimex", "Lika";

Dentin protection - with varnishes or pads "Komposil", "Tsimex", "Lika";

Application of the adhesive system (Clerafil Liner Bond 2V, Panavia F), Lika, Cimex, Komposil.

Application of filling material "Tsntrix"

Requirements for treatment results:

No hypersensitivity

No recurrent caries;

restoration of functional, anatomical and aesthetic parameters of the tooth.
^

V. PREVENTIVE SEALING OF TEETH FIGURES

SURVEY

It is carried out to identify the type of fissures that are subject to preventive sealing. Inspection, staining, instrumental examination.

^ EVENT CHARACTERISTICS

Cleaning the fissure with Radent paste;

Sealing the fissure with Titmate sealant or treatment with Saforaid.

Requirements for sealing results:

Absence of carious lesions of fissures.

^ VI. COMPLICATIONS OF CARIES

VI. I PULPITIS

(Acute, chronic, in the acute stage). Inflammation of the pulp and tooth, mostly with pain.

INSPECTION:

questioning, examination, instrumental examination, electroodontodiagnosis, temperature test, x-ray examination.

^ CHARACTERISTICS OF TREATMENT MEASURES:

Anesthesia

Removal of the pulp under anesthesia or with the preliminary application of devitalizing agents: arsenic paste;

Mechanical and medicinal treatment of root canals using sodium hypochlorite solution "Neoklzner Sikain";

Filling root canals with Vitapex paste and other types of pastes with gutta-percha;

Application of an insulating pad;

In case of significant curvature of the root canals and in other cases when complete removal of the pulp is impossible, the mummifying drug "Neo Triozinc Paste" should be used.

Requirements for treatment results:

Stopping pain;

Absence of destructive processes in the periodontium in the long term.

VI. II^ PERIODONTITIS, APICAL

(Acute, chronic, in the acute stage). Pulp necrosis with destructive changes in the periodontium.

INSPECTION:

questioning, examination, instrumental examination, x-ray examination.

^ CHARACTERISTICS OF TREATMENT MEASURES FOR CONSERVATIVE TREATMENT OF APICAL PERIODONTITIS:

In the acute period - pain relief

Preparation and opening of the tooth cavity;

Removing the contents of the root canal and exudate with copious rinsing with antiseptic solutions;

Mechanical treatment of the root canal using EDTA;

When treating acute and aggravated forms of periodontitis, the tooth is left open for 3-7 days. According to indications, antibiotics are prescribed in combination with antihistamines; mandatory rinsing;

After stopping the acute process and in the presence of a chronic process in the presence of zones of periapical destruction of bone tissue, temporary obturation of the root canals should be used using osteotropic drugs: “Iodo-glycol paste”.

Before the final obturation, medicinal treatment and drying of the root canal are carried out;

Obturation of the root canal using the Vitapex material, if necessary, in combination with gutta-percha;

Application of an insulating gasket "Cimex";

Application of a permanent filling.

Requirements for treatment results:

Stopping pain;

In the long term - restoration of bone tissue in the destruction zone.

^ Superficial caries

No complaints. He came for the purpose of sanitation of the oral cavity. Objectively: a carious cavity on the medial surface of the 16th tooth is located in the center of a large chalky spot, within the enamel.

Complaints of short-term pain from chemical irritants (sweet, sour, salty).

Objectively: a carious cavity on the chewing surface within the enamel, probing is painless; EDI=3 µA.

Diagnosis: superficial caries of the 16th tooth.

Treatment: preparation of the carious cavity, medicinal treatment with 3% sodium hypochloride solution, filling from Valux plus CPM.

^

Average caries

Treatment: preparation of the carious cavity, medicinal treatment with 3% sodium hypochloride solution, filling from Valux plus CPM.

Complaints of short-term pain when eating sweet foods.

Objectively: a carious cavity on the chewing surface of the 27th tooth, within its own dentin, probing is painless, there is no reaction to temperature stimuli; EDI=5 µA.

Diagnosis: average caries of the 27th tooth.

Treatment: preparation of the carious cavity, medicinal treatment with 3% sodium hypochloride solution, filling from Valux plus CPM.

Complaints of short-term pain when eating.

Objectively: a carious cavity on the chewing surface of the 27th tooth, within its own dentin, probing is painless, there is no reaction to temperature stimuli. Preparation syndrome positive (preparation is painful)

Diagnosis: average caries of the 27th tooth.

Treatment: preparation of the carious cavity, medicinal treatment with 3% sodium hypochloride solution, filling from Valux plus CPM.
^

Deep caries

Complaints of short-term pain from temperature stimuli.

Objectively: the chewing surface of the 46th tooth is deep

carious cavity within the peripulpal dentin, probing is painful along the entire bottom, a sharp reaction to a cold stimulus, the pain goes away immediately after the stimulus is removed.

Diagnosis: deep caries of the 46th tooth.

Treatment: preparation of a carious cavity, medicinal treatment with 3% sodium hypochloride solution, calcium hydroxide (Dycal) on the bottom, gasket (Duract), filling made of CPM Valux plus.

Complaints of pain in the 46th tooth when eating.

Objectively: on the chewing surface of the 46th tooth there is a deep carious cavity within the omolopulpal dentin, probing is painful along the entire bottom, the dentin is dense, there is no communication with the pulp chamber.

Diagnosis: deep caries of the 46th tooth.

Treatment: preparation of a carious cavity, medicinal treatment with 3% sodium hypochloride solution, calcium hydroxide (Dycal) on the bottom, gasket (Duract), filling made from KPM Valux plus.

PULPITES

Complaints of sharp pain in the 18th tooth for 2 days. Objectively: in the 18th tooth there is a deep carious cavity within the ojuulopulpar dentin, filled with softened dentin, probing is painful in the area of ​​​​the projection of the medial pulp horn, the tooth cavity is not opened. Percussion is painless.

Diagnosis: acute focal pulpitis of the 18th tooth.

Treatment: under infiltration anesthesia Sol. Ultracaini 2%-1.7 ml preparation of the carious cavity, medicinal treatment with 3% sodium hypochloride solution on the bottom, calcium hydroxide (Dycal), gasket (Dyract), filling from KPM Valux plus.

Complaints of pain when eating for 2 days. Objectively: in the 18th tooth there is a deep carious cavity within the peripulpal dentin, filled with softened dentin, probing is painful in the area of ​​​​the projection of the medial pulp horn, the tooth cavity is not opened. Percussion is painless; EDI==12 µA. Diagnosis: acute focal pulpitis of the 18th tooth. Treatment: under infiltration anesthesia Sol. Ultracaini 2%-1.7 ml, preparation of the carious cavity was carried out, medicinal treatment with 3% sodium hypochloride solution, calcium hydroxide (Dycal) on the bottom, gasket (Dyract), filling from KPM Valux plus.

Acute diffuse pulpitis

Objectively: on the chewing surface of the 26th tooth there is a deep carious cavity within the peripulpal dentin, the pulp chamber is not opened, probing is painful, percussion is sharply painful.

Treatment: under infiltration anesthesia Sol. Ultracaini 2%-1.7 ml carried out preparation of a carious cavity, opening of the tooth cavity, deep amputation of the coronal and extirpation of the root pulp, expansion of the root canals and medicinal treatment with 3% sodium hypochloride solution, filling of the root canals AN-26. Temporary filling. Referral for control radiography.

On the radiograph dated May 16, 2005, the root canals of the 26th tooth are filled to the physiological apexes. Filling made from KPM Herculite XRV.

Complaints of sharp paroxysmal, long-lasting pain from a hot temperature stimulus. Cold pain The tooth had not previously hurt.

Objectively: on the chewing surface of the 26th tooth there is a deep carious cavity within the peripulpal dentin, the pulp chamber is not opened, probing is painful, percussion is sharply painful; EDI=25 µA.

Diagnosis: acute diffuse pulpitis of the 26th tooth.

Treatment: under infective anesthesia Sol. Ultracaini 2%-1.7 ml prepared the carious cavity and opened the tooth cavity. deep coronal amputation and extirpation of root pulp, expansion of root canals and drug treatment with 3% hypochloride solution pain. The pain intensifies in the evening and at night. The tooth had not previously been sick. Sodium, root canal filling AN-26. Temporary filling. Referral for control radiography.

On the X-ray dated May 17, 2005. The root canals of the 26th tooth are sealed to the physiological apexes. Filling made from KPM Herculite XRV.

Complaints of spontaneous, paroxysmal, long-lasting, radiating pain.

Objectively: there is an acrylic oxide filling on the chewing surface of the 26th tooth, percussion is sharply painful; EDI 20 µA.

Diagnosis: acute diffuse pulpitis of the 26th tooth.

Treatment: under infiltration anesthesia Sol. Ultracaini 2%-1.7 ml: removal of the filling, opening of the tooth cavity, deep amputation of the coronal and extirpation of the root pulp, expansion of the root canals and medicinal treatment with 3% sodium hypochloride solution, filling of the root canals AN-26. Temporary filling. Referral for control radiography. On the X-ray dated May 18, 2005. The root canals of the 26th tooth are sealed to the physiological apexes. Filling made from KPM Herculite XRV.

Chronic fibrous pulpitis

No complaints.

Objectively: on the chewing surface of the 26th tooth there is a deep carious cavity communicating with the tooth cavity, probing is sharply painful at this point, the pulp is bleeding,

Treatment: under tuberal anesthesia Sol. Lidocaini 2%-4.0%, preparation of the carious cavity, deep amputation of the coronal and extirpation of the root pulp, mechanical expansion of the root canals, medicinal treatment with 3% sodium hypochloride solution, filling of the root canals AN-26 were carried out. Temporary filling. Referral for control radiography.

On the x-ray dated May 19, 2005, the root canals of the 26th tooth are sealed to the physiological apexes. Filling made from KPM Herculite XRV.

Complaints of aching pain and discomfort in the tooth when approaching from a cold to a warm room.

Objectively: on the chewing surface of the 26th tooth there is a deep carious cavity communicating with the tooth cavity, probing is sharply painful at this point, the pulp is bleeding; EDI = 40 µA.

Diagnosis: chronic fibrous pulpitis of the 26th tooth.

Treatment: under tuberal anesthesia Sol. Lidocaini 2%-4.0, preparation of the carious cavity, deep amputation of the coronal pulp and extirpation of the root pulp, mechanical expansion of the root canals, medicinal treatment with 3% sodium hypochloride solution, filling of the root canals AN-26 were carried out. Temporary filling. Referral for control radiography.

On the x-ray dated May 20, 2005, the root canals of the 26th tooth are filled to the physiological apexes. Filling made from KPM Valux plus.

Complaints of pain when eating food at contrasting temperatures.

Objectively: the crown of the 26th tooth is significantly destroyed, there is a deep carious cavity on the chewing surface, communicating with the cavity of the tooth, probing is sharply painful at this point, the pulp is bleeding.

Diagnosis: chronic fibrous pulpitis of the 26th tooth.

On the radiograph dated May 21, 2005, the root canals of the 26th tooth are filled to the physiological apexes. Filling made from KPM Herculite XRV.

Complaints of aching pain while eating food of contrasting temperatures and transitioning from a cold room to a warm one.

Objectively: there is a filling on the chewing surface of the 26th tooth, percussion is painless, EDP = 35 µA.

Diagnosis: chronic fibrous pulpitis of the 26th tooth.

Treatment: under tuberal anesthesia Sol. Lidocaini 2%-4.0, preparation of the carious cavity, deep amputation of the coronal pulp and extirpation of the root pulp, mechanical expansion of the root canals, medicinal treatment with 3% sodium hypochloride solution, filling of the root canals AN-26 were carried out. Temporary filling. Referral for control radiography.

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.

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

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Exacerbation of chronic periodontitis

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

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), removal of 48, 47, 46, 45, 44, 43, 33, 34, 35, 36, 37, 38 was performed.

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

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.