Algorithm for issuing a "medical record of a dental patient. Recommendations for students on filling out a medical record of a dental patient with defects in hard dental tissues Discharge summary of a dental patient

Since the creation of the modern structure of dental care, the medical record of the dental patient has been its basic element. It existed when other documents, without which it is impossible to imagine the work of a modern clinic, (contract, protocol of voluntary informed consent, insurance policy, etc.) were not yet known at all.

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 modernize, modify, invent their own options. And if the use of various variations on the theme of the medical record of a dental patient can be understood (in many respects the existing form is already lagging 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?

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

Registration of a medical card of a dental patient -

The medical card of a dental patient is issued in accordance with the orders of the USSR Ministry of Health No. 1030 dated 04.10.1980 and No. 1338 dated 12.31.1987. At the same time, the Ministries of Health of the USSR and the Russian Federation managed to arrange extreme confusion with the medical card. In 1988, an order of the Ministry of Health of the USSR (No. 750 dated 05.10.1988) was issued, 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 the order of the Ministry of Health of the USSR No. 1030, making appropriate changes and additions to it.

There are no later basic orders or other acts of the Ministry of Health of Russia establishing the form of a medical card. Therefore, although many provisions of Order No. 1030 have become invalid, references periodically appear in new regulatory documents to those parts of the order that relate to the maintenance of medical records. In particular, the requirement remains that all medical institutions (we note, regardless of the form of ownership) are required to keep medical records of the established form. In dentistry, this is Form No. 043 / y "Medical record of a dental patient."

What does a medical card include?

Medical card No. 043 / y contains three main sections.

1) First section- passport part. It includes:

• Card number;
• the date of its issuance;
• surname, name and patronymic of the patient;
• patient's age;
• gender of the patient;
• address (place of registration and place of permanent residence);
• profession;
• initial diagnosis;
• information about past and concomitant diseases;
• information about the development of the present (which became the reason for the primary treatment) disease.

This section may be supplemented by 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 examination data;
• oral examination data and a table of the condition of the teeth, 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);
• bite description;
• description of the state of the oral mucosa, gums, alveolar processes and palate;
• X-ray and laboratory data.

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

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

Some features of the medical card

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

All other entries in the medical record are made only by a doctor, legibly, without corrections (a printed (computer) version of making an entry is possible), using only generally accepted abbreviations. The wording of diagnoses, anatomical formations, the names of instruments and medicines 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 entries, the following must be entered in the medical record (pasted):

• test results (if any) - originals or copies;
• extracts from other medical institutions where dental care was provided, especially if dental care was provided in other institutions after the patient first applied (began to be observed) in this dental clinic;
• medical opinions, expert opinions, consultations received in connection with the diseases for which the patient is observed in this clinic;
  medical opinions, expert opinions, consultations received in connection with other diseases, the course of which may affect the characteristics of a dental disease;
• information on oncological examinations (on the basis of the order of the Ministry of Health of the Russian Federation "On measures to improve the organization of oncological care for the population of the Russian Federation" No. 270 dated September 12, 1997);
• information on the doses of radiation exposure 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 exposure doses to personnel and the public” No. 466 dated December 31, 1999);
• x-rays of the patient's teeth and maxillofacial area, performed 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 the services provided, x-rays are of the greatest importance. Why? For example, let's analyze a controversial situation that occurs most often.

The patient treated his teeth in several clinics and took his x-rays everywhere after the end of the treatment. At the same time, of course, in all clinics there were certain documents confirming the fact of treatment (contracts for the provision of services, entries in the medical record, receipts for payment, checks, etc.). In one of the clinics, during treatment, an instrument broke off in the canal of the tooth. However, the patient did not sue the clinic where the instrument was broken, but the richest of those where he was treated.

At the same time, it is practically impossible to prove the absence of the fault of the clinic indicated in the claim if the clinic cannot present an x-ray taken after the completion of the treatment. That is why the clinic is extremely interested that all the images taken by the patient remain with her. However, there are certain legal difficulties here.

The fact is that radiography is usually included in the price list by clinics as a separate type of service. And on the basis of the Civil Code of the Russian Federation and the Law "On Protection of Consumer Rights", the patient has the right to regard the performed x-ray as a paid service, the material expression (result) of which is an x-ray. Accordingly, the patient acquires the full right to take this picture 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 the x-rays performed in the clinic are an integral part of the medical record of the dental patient. In this case, all images taken in the clinic remain its property on the basis of an agreement concluded with the patient.
2. 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 the dental patient form No. 043 / y. If the dental clinic uses its own form of medical record, then it can have serious problems during the trial. The fact is that the patient can file a petition for the clinic to provide evidence of a medical record of a dental patient of a statutory form (form No. 043 / y).

In this case, the provision by the dental clinic of a medical card of a different form may be interpreted by the court as a formal basis for recognizing this form as not complying with 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 reason to accuse the clinic of improper record keeping.

Since this form of the map is really morally 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, an insert sheet to the medical record (information sheet) is used, taking into account the specific features of a particular clinic. It is much worse for the dental clinic if the medical record of the dental patient is not kept at all.

Frequently asked Questions -

1. Who makes entries in the medical record?
   The passport part is filled in by the registrar, administrator or nurse, all other entries are made only by the doctor.
2. How are medical records entered?
   Legibly, using only generally accepted abbreviations, without corrections, handwritten or in printed form, assuring the signature and personal seal of the doctor.
3. What is a medical card for?
   For reasonable protection of the interests of the dental clinic, primarily in court.
4. Can dentistry issue a medical card to a patient?
   Formally yes, actually no.
5. What can be the problems for using the wrong card options?
   An incorrect version of the card may not be recognized by the court as written evidence, and the resulting lack of documentation required by law may result in legal claims.
6. Does the patient have the right to take x-rays?
   Yes, at least copies of photographs on paper or other media.
7. How do dentists modernize the medical record?
   Use the insert in the medical record - information sheet.

AT THE DEPARTMENT OF ORTHOPEDIC DENTISTRY

Medical card of a dental patient

The main document for recording the work of a dentist of any specialty is a medical record of a dental patient form 043-u, approved by order of the Ministry of Health of the USSR No. 000 dated 01.01.2001.

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

is a plan for a thorough examination of the patient;

Count "Allergological History" the patient is asked if there were any allergic reactions to medications, household chemicals, food products, etc., whether anesthesia was previously used, and whether any complications were noted after it was performed.

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

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

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

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

The nature of the movements of the lower jaw;

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

Example: The face is symmetrical and proportionate. Full mouth opening. The movements of the lower jaw are free, uniform.

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

Example:

PWithRShtZ P K K

1812 11 !26 27 28

4842 41 !36 37 38

S PP K K

In the dental formula, in accordance with the conventions, all teeth are marked ( P- sealed; FROM- with carious cavities, R – with significantly or completely destroyed crown part); degree of tooth mobility 1, P, W, 1U), teeth with orthopedic constructions ( To- artificial crowns ShtZ- pin tooth), etc.

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

Example:

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

14 - on the medial surface there is a small carious cavity, probing the cavity is painless.

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

11 - artificial metal-plastic crown, plastic lining is changed in color, there is hyperemia of the marginal edge of the gums.

21 - the coronal part is changed in color, the medial angle of the cutting edge is chipped, the tooth is stable, located in the dental arch, percussion is painless.

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

31, 32, 41, 42 - dental deposits, slight hyperemia of the gingival margin.

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

46 - on the occlusal surface there is a large filling, changed in color, when probing, a violation of the marginal fit is determined, a chip of the medial lingual tubercle, the tooth is stable, percussion is painless.

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

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

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

The state of the crown - the presence of a carious cavity, fillings, the ratio of the bottom of the carious cavity to the tooth cavity;

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

the state of the roots: quantity, shape, size, contours;

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

assessment of the periodontal gap: uniformity, width;

The state of the compact plate of the hole: preserved, destroyed, thinned, thickened;

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

assessment of the surrounding tissues: the state of the interdental septa - height, the state of the end compact plate.

Example:

On intraoral x-rays of satisfactory quality:

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

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

11 – in the region of the coronal part, an intense shadow of the metal frame of the artificial crown is projected, in the root canal up to ½ of its length, an intense shadow of the metal wire pin is traced. In the apical third of the root canal, the shadow of the filling material is not determined. Uniform expansion of the periodontal gap. In the region of the root apex, there is a focus of rarefaction of bone tissue with fuzzy contours in the form of "tongues of flame".

21 – a chip of the medial angle of the cutting edge of the coronal part, in the root canal there is an intense shadow of the filling material with filling defects. No changes were found in the periapical tissues.

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

32, 31, 41, 42 – pathology of hard tissues was not revealed, interdental septa are reduced to 1/3 of the length of the roots, there is a lack of end compact plates, the tops have a "scalloped" appearance.

The same column describes the data of electroodontodiagnostics and other examination methods (for example, the results of tomography of the temporomandibular joints in patients with signs of a decreasing bite).

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

When making a diagnosis, it is necessary to highlight:

main disease of the dentoalveolar system and complication of the main disease;

concomitant dental diseases;

common comorbidities.

The main diagnosis should be detailed, descriptive and comply with the international classification of nosological forms of dental diseases based on the ICD -10 C.

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

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

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

“Complete defect of the crown part of the 13th tooth of carious origin (IROPZ more than 0.8). Functional and aesthetic insufficiency of the artificial crown of the 12th tooth. Partial defect with a change in the color of hard tissues of the 21st tooth of traumatic origin.

The second component of the main diagnosis is functional part, characterizing dysfunctions, movements of the lower jaw. For example, "Aesthetic insufficiency of the dentition of the upper jaw", « Functional insufficiency of the dentition of the lower jaw», "Blocking movements of the lower jaw."

In the above example, the full wording main diagnosis as follows:

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

AT concomitant dental diagnosis all identified dental pathology is taken out, which will be treated by dentists, dental surgeons, orthodontists (for example, caries, chronic periodontitis, gingivitis, periodontitis, diseases of the oral mucosa, etc.).

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

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

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

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

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

Special preparation of teeth is carried out according to prosthetic indications and is necessary for more effective orthopedic treatment and to exclude the possibility of developing complications after treatment.

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

refilling of root canals;

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

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

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

the anatomical shape of the tooth crown;

unity of the dentition;

· lost functions and aesthetics.

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

Example:

"Restore the anatomical shape of the coronal part

tooth 16 – cast all-metal crown;

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

pin tabs;

tooth 21 – ceramic-metal crown;

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

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

Example:

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

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

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

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

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

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

In chapter "A diary» describes the clinical stages of orthopedic treatment, indicating the date of admission of the patient and the date of the next appointment. We give examples of filling "Diary" depending on the design of the denture in the orthopedic treatment of defects in the hard tissues of the teeth.

The final section of the medical history of the dental patient "Epicrisis" filled in according to a certain scheme:

Patient (full name) 27.02.09 applied to the clinic of orthopedic dentistry with complaints about _______________________________________.

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

Orthopedic treatment performed _____________________________

____________________________________________________________

The anatomical shape of the crowns of the teeth, the integrity of the dentition of the upper jaw, the lost functions and the aesthetic norm were restored.

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

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 patient data and the course of treatment.

A dental patient card form 043 y is issued to all citizens who have applied for help. The document exists in one copy for each patient. The number of specialists involved in the treatment of the patient does not matter. All data is summarized in 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 a contract for the provision of dental services, which must be signed by the patient after reading the text of the contract. 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 y must contain the patient's passport data. This sheet is filled out at the register. The basis is the documents proving the identity of the applicant. The patient enters information about his health into the card.

Information about the state of health should include such important parameters as the presence of allergies, blood type and Rh factor, chronic diseases of internal organs, head injuries, current medications, and so on. It is very important to include 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 a visual examination and x-ray studies. The use of an x-ray machine involves irradiation of the patient. The received dose of radiation must also be recorded in the card.

Pages with the results of the examination, data on the diagnosis and the course of treatment are filled in by specialists who carry out the corresponding procedures. The patient must document their consent to the examination and treatment plan.

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

Medical card 043 y is the property of the clinic.

According to the instructions, the dental card form 043 is not handed out. This legal document can be used in the event of litigation and claims from the patient. The card is stored in an outpatient dental facility for 5 years. After this period, the form is transferred to the archive of the organization. The period of storage in the archive is 75 years.

Unlike most established forms of medical forms, form 043 y is advisory. The form can be supplemented and adjusted to the needs of a particular medical institution. It is possible to order such an adjustment of the form in the City Blank printing house, taking into account all the requirements of the customer.

The document can be reduced, supplemented, correct columns. To preserve the protective functions of the document, it is recommended not to exclude important items 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 medical card of a dental patient both in a single copy and 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.

I note that this tool can be ineffective if the maintenance of a medical record of a dental patient is not taken seriously enough. There is an expression that a doctor writes a medical record for the prosecutor, in fact, the doctor writes it exclusively for himself, for his own 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 an 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 the medical record as a means of protection, then two equally important blocks can be distinguished: the form of the medical record and its content.

Form of a medical card of a dental patient

New medical documentation forms were approved by order of the Ministry of Health of Russia No. 834n dated December 15, 2014. Prior to this, forms were used for a long time by 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, now it contains about 12 forms, but it is not always clear why they were included in the order. For example, there is no general form for a dental patient. But there appeared an orthodontic card of a dental patient, which was developed to a greater extent for scientific activity.

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

Questions also sometimes arise about the use of electronic health records, while everyone has three completely different things in mind:

The first option is when 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, it is pasted into the medical record. This is an acceptable option, the best one today, because, as a rule, a lot is taken into account in the program, and everything is clear.

In the second option, software is also used, but the dental patient's medical record is kept only in electronic form, it is stored in the computer's memory, not printed. In the event of a conflict situation in court, such a medical record will most likely be recognized as inadmissible evidence.

The third, ideal option, which is envisaged by the state program for the development of health care until 2020, is the "Electronic medical record". 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. An uninterrupted power supply with the possibility of constant access must be provided, the protection of personal data and the impossibility of losing information must be proven. It is also necessary that patients and doctors can put a digital signature on 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. Often doctors use English and Latin terms that are not always clear to the patient, and he must understand everything that is written in his card. This also applies to abbreviations, of course, there are official, generally accepted abbreviations, but sometimes doctors cut much more than the generally accepted one. In this case, you need to make a list of your abbreviations, print it out and paste it on the card so that the client also understands them.

As for the corrections made to the card: the use of a stroke, "scribble", sticking pieces of a 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 may be interested

• Checking on a patient's complaint to a dental clinic

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

1. "Given" is what the patient comes to your clinic with. "Given" - these are complaints described in detail, necessarily in detail. Write down all complaints, pain sensations, describe the oral cavity in detail, especially if the patient came from another clinic, because, in the event of a trial, it will be quite problematic to get an extract from there. Immediately you need to fix the situation with which the patient came. "Dano" also includes an x-ray, its obligatory description. If you are doing large-scale work in orthopedics, orthodontics, surgery in the clinic, it is desirable that you have at least a quarter of the rate, a part-time radiologist. "Dano" includes photographs of treatment, that is, photo-recording, which is carried out where the aesthetic result is important, there must be pictures "before". 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 detailed you describe, the more significant this record will play in protecting the doctor.
3. Result. Mandatory photo-recording, if the aesthetic moment matters, mandatory recording of the recommendations that you give to the patient in order to save the result. A recommendation is the most powerful thing in defending a medical organization in court. If the recommendations were prescribed, and the patient ignored them, then all charges can be dropped from the clinic in court. In order for recommendations to save you, two factors must be taken into account. You must prove that:

• you made recommendations
• these recommendations were not implemented.

Therefore, the client's signature must be under the recommendations, and the phrase: “Recommendations have been given” will not save in this situation. The result also includes notifications of the necessary appearances, this is also a moment that is taken into account in court. Recommendations can be written in the medical record every time, or you can develop a single list where all recommendations will be collected regarding the manipulations that you perform, and the patient only puts his signature, confirming that he is familiar with them.

Notify the patient of required appointments. If the date of appearance and the fact of non-appearance are fixed, then this also works in favor of the clinic in conflict situations. Also, if the patient did not come to the appointment, 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, were interested in his arrival.

The diagnosis must be made according to the 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 map according to both classifications: according to the generally accepted ICD-10 and dental.

A very important point is the coordination of the treatment plan and its modification. We are talking about long-term manipulations (orthopedists and orthodontists), where you can hardly name a strict deadline, situations where the price can change, because one of the treatment methods did not work. It is imperative to write down the initial plan, with the timing 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 on the type of work, volume, time and price with him. It is also mandatory to prescribe the warranty periods, as well as the reasons why they were reduced, if this happened.

Terms of storage of a medical record of a dental patient

According to the new rules, the patient's medical record must now be kept not for 5 years (Order of the Ministry of Health of the USSR No. 1030 of 04.10.1980), but for 25 years (Letter of the Ministry of Health of the Russian Federation of 07.12.2015 No. 13-2 / 1538).

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

Do not forget, the medical card has actually become part of the contract with the patient. It is necessary to have the patient's signature in the card, this is a confirmation of complaints, anamnesis, services rendered, recommendations, the need for appearances.

• Afanasiev V.V., Barer G.M., Ibragimov T.I. Dentistry. Recording and maintaining a medical history: A practical guide. M.: VUNMTs Roszdrav, 2006.
• Saversky A.V. The rights of patients 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: TsNIT, 2004.

IV. SAMPLES OF COMPLETING THE MEDICAL CARD OF A DENTAL PATIENT IN THE TREATMENT OF MAIN DENTAL DISEASES

OPTIONS FOR RECORDING THE HISTORY OF DISEASE OF PATIENTS WHICH PPROVIDED TOOTH REMOVAL AND OTHER SURGICAL MANIPULATIONS

Exacerbation of chronic periodontitis

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

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

local changes. On external examination, there is no change. Submandibular lymph nodes are slightly enlarged on the left, painless on palpation. The mouth opens freely. In the oral cavity: under a filling, changed in color, its percussion is painful. In the region of the tops of the roots 27, a slight swelling of the mucous membrane of the gums is determined from the vestibular side, palpation of this area is slightly painful. On radiograph 27, the palatine root is sealed to the apex, the buccal roots are 1/2 of their length. At the apex of the anterior buccal root there is a rarefaction of bone tissue with fuzzy contours.

Diagnosis: "exacerbation of chronic periodontitis 27 tooth".

a) Under tuberal and palatine 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 the tooth), curettage of the hole; hole filled with blood clot.

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

c) Under infiltration and palatine anesthesia (anesthetics, see entry above, indicate the presence of adrenaline), removal was performed (15, 14, 24, 25). Curettage of the hole (holes), the hole (s) filled (were) with a blood clot (s).

d) Under infraorbital and palatine anesthesia (anesthetics see above, indicate the presence of adrenaline) ( 15, 14, 24, 25).

e) Under infiltration and incisive anesthesia (anesthetics see 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.

f) Under infraorbital and incisive anesthesia (anesthetics see above, indicate the presence of adrenaline), the 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 a "grown" tooth. The general condition is satisfactory; past illnesses: pneumonia, childhood infections.

History of the disease. About a year ago, for the first time, pain appeared at 32, it was especially disturbing at night. The patient did not go to the doctor; gradually the pain subsided. 32 days ago, pain reappeared; went to the doctor.

local changes. On external examination, there are no changes. The submental lymph nodes are slightly enlarged, 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, edematous. There are no changes on the radiograph 32.

Diagnosis: "acute purulent periodontitis 32".

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

b) Under torusal anesthesia (anesthetics see 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 (anesthetics see above), removal of 42, 41, 31, 32 was performed. Curettage of the hole, it was compressed and filled with a blood clot.

d) Under infiltration anesthesia (anesthetics, see 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 cheek on the right, pain in this area, fever.

Past and concomitant diseases: duodenal ulcer, colitis.

History of the disease. Five days ago there was pain at 13; Two days later, a swelling appeared in the gum area, and then in the buccal area. The patient did not go to the doctor, applied a heating pad to his cheek, did warm intraoral soda baths, took analgesics, but the pain grew, the swelling increased, and the patient went to the doctor.

local changes. During external examination, a violation of the configuration of the face is determined due to swelling in the buccal and infraorbital regions on the right. The skin above it is not changed in color, painlessly gathers into a fold. The submandibular lymph nodes on the right are enlarged, compacted, slightly painful on palpation. The mouth opens freely. In the oral cavity: 13 - the crown is destroyed, its percussion is moderately painful, mobility II - III degree. Pus is released from under the gingival margin. The transitional fold in the area of ​​14, 13, 12 swells significantly, is painful on palpation, fluctuation is determined.

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

Complaints of swelling of the lower lip and chin, extending to the upper part of the chin area; sharp pains 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 carry out treatment, he turned to the clinic on the 4th day of the disease.

Past and concomitant diseases: influenza, tonsillitis, intolerance to penicillin.

local changes. During external examination, swelling of the lower lip and chin is determined, its soft tissues are not changed in color, they fold freely. The submental lymph nodes are slightly enlarged, slightly painful on palpation. Opening the mouth is not difficult. In the oral cavity: the transitional fold in the region of 42, 41, 31, 32, 33 is smoothed, its mucous membrane is edematous and hyperemic. On palpation, a painful infiltrate in this area and a positive symptom of fluctuation are determined. Crown 41 is partially destroyed, its percussion is slightly painful, I degree mobility. Percussion 42, 41, 31, 32, 33 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 (anesthetic see 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

(indicate within which teeth) 3 cm (2 cm) long to the bone. Got pus. The wound was drained with a rubber strip. Assigned (indicate the medications prescribed to the patient, their dosage).

The patient is disabled from _______ to _________, sick leave No. ______ issued. Appearance ______ for dressing.

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

The patient's condition is satisfactory. Improvement (or deterioration, or no change) is noted. Pain in the jaw area has decreased (or increased, remains the same). The swelling of the maxillary tissues has decreased, 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 furacilin at a dilution of 1:5000. A rubber strip has been inserted into the wound (or the wound has been drained with a rubber strip)

Complaints of pain in the hard palate on the left of a pulsating nature and the presence of swelling on the hard palate. The pain is aggravated by touching the swelling with the tongue.

History of the disease. Three days ago, there was pain in the previously treated 24, pain when biting, feeling of a “grown 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: hypertension II degree, cardiosclerosis.

local changes. During external examination, the configuration of the face was not changed. On palpation, an increase in the submandibular lymph nodes on the left is determined, which are painless. Mouth opening freely. In the oral cavity: on the hard palate on the left, respectively 23 24 there is a disgraced bulging with fairly clear boundaries, the mucous membrane over it is sharply hyperemic. Fluctuation is determined in the center of it. 24 - the crown is partially destroyed, a deep carious cavity. Percussion of the tooth is painful, tooth mobility I degree.

Diagnosis: "acute purulent periostitis of the upper jaw on the palatine side on the left (palatine abscess) from the 24th tooth."

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

The patient is disabled from _______ to _______., A sick leave sheet No. _______ was issued. Appearance _________ for dressing.

Acute purulent osteomyelitis

Complaints of shooting, boring pains in the region of the entire half of the lower jaw on the right, severe weakness, fever up to 39ºС, chills, sweating, bad breath.

The patient has no past or concomitant diseases.

History of the disease. Five days ago, pain appeared in the previously treated 46, pain when biting, swelling of the gums and cheeks on the right. There was chills at night. In the morning I went to the doctor. The tooth has been removed. Improvements have not come. Increased pain in the jaw, general weakness; there was numbness of the skin of the lower lip on the right, bad breath. Soft tissue swelling increased, body temperature increased.

local changes. An external examination reveals a significant swelling in the submandibular and buccal areas on the right, the skin above it is hyperemic, tense, and does not fold. Palpation of tissues is painful. Pain sensitivity of the skin of the lower lip and chin on the right is reduced. Palpation of the lower edge of the body of the lower jaw on the right is sharply painful. In the oral cavity: the mucous membrane of the alveolar part of the lower jaw in the area 48, 47, 46, 45 from the vestibular and lingual sides is edematous and hyperemic. Percussion 47, 45 is sharply painful, the teeth are mobile. Bulging is determined along the transitional fold in the area of ​​48, 47, 46, 45 from the vestibular side, infiltration of the soft tissues of the alveolar process in the area of ​​these teeth from the lingual side. Hole 46 exudes pus.

Diagnosis: "odontogenic acute purulent osteomyelitis of the lower jaw on the right, inflammatory infiltrate of the submandibular and buccal regions on the right."

Under torusal anesthesia (specify the anesthetic), an incision was made along the transitional fold to the bone in the area of ​​47, 46, 45, 44, pus was obtained, and an incision was made in the area of ​​the alveolar or germ from the lingual side (to the bone) within these teeth, no pus was obtained, stagnant blood was obtained. Wounds are drained with rubber strips. Drug therapy was prescribed (specify which one). The patient is disabled from _______ to, a sick leave sheet No. ______ was issued. Appearance _______ for dressing.

Odontogenic cystogranuloma

Complaints about recurring pain in 11. The tooth was previously treated with canal filling. He considers himself practically healthy.

local changes. During external examination, the configuration of the face was not disturbed. Submandibular and parotid lymph nodes are not palpable. The mouth opens freely. In the oral cavity: the mucous membrane is pale pink, well moistened. On palpation of the alveolar part of the upper jaw from the vestibular side, a slight swelling is detected in the projection area of ​​the apex 11. On the radiograph in the area of ​​the apex 11, there is a rarefaction of the bone tissue of a rounded shape with clear contours with a diameter of 0.6 cm. Channel 11 is sealed with cement for 2/3.

Diagnosis: "cystogranuloma in area 11".

Recording of root apex resection operation

Under conduction (specify which) and infiltration anesthesia (specify the anesthetic and adrenaline solution, if any), a semi-oval (or trapezoid) incision was made in the soft tissues of the alveolar process to the bone. A flap has been formed with its base facing the transitional fold. The mucoperiosteal flap was detached in the area (indicate the formula of the teeth). An uzura was found in the compact plastic of the alveolar process (if any), which was expanded with a burr. The apex of the root was identified with a granuloma, the apex of the root was resected (indicate the formula of the tooth) with the help of a fissure bur, which was removed with a curettage spoon along with a cystogranuloma. The protruding part of the root is smoothed with a cutter to the bottom of the bone cavity. The wound was washed with a solution of furacilin 1:5000 and a solution of 0.05% chlorhexidine. The flap is placed in place and fixed with catgut sutures. Pressure bandages applied. Medical therapy was prescribed (specify which one).

The patient is disabled from _____ to __________, a sick leave sheet No. ______ is issued.

Appearance _______ for dressing.

Semi-retention and dystopia of teeth

Complaints of recurrent pain in the lower jaw on the left and difficulty opening the mouth. Past and concomitant diseases: influenza, intolerance to penicillin.

History of the disease. He considers himself sick for about 1 year. In January 2008 for the first time felt the appearance of painful swelling of the gums in area 37 and some difficulty in opening the mouth. He turned to the district clinic, where the treatment was carried out: 5 sessions of UHF therapy on the area of ​​​​the angle of the lower jaw, took norsulfazol inside, and made baths with baking soda. The phenomena mentioned above subsided. He was referred for a consultation to the regional clinical dental clinic.

local changes. On external examination, the configuration of the face is not disturbed; on palpation, an enlarged (1 cm in diameter), painless, movable submandibular lymph node on the left is determined. Opening of the mouth is free, painless. In the oral cavity: the mucous membrane of the vestibule of the mouth is pale pink in color, sufficiently moistened. 38 was cut through by two distal tubercles, displaced towards 37.

On the radiograph, the crown 38 is displaced anteriorly, with medial tubercles adjacent to the root 37.

Diagnosis: "half-retention and dystopia 38".

Recording of tooth extraction with flap flap

Under infiltration or conduction (in this case, indicate which) anesthesia (anesthetic see above), an angular (or trapezoidal, semi-oval) incision was made and the mucoperiosteal flap was detached 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

(indicate within which teeth). A compact plate of alveolar bone tissue was trepanned with a burr in the area (indicate the formula of the tooth to be removed) from the vestibular side (when removing 48, 38 - additionally in the retromolar region). The bone tissue was removed with a burr.

The tooth was dislocated with an elevator and removed with forceps. The wound was washed with a 3% hydrogen peroxide solution, chonsuride (oxycelodex, hydroxyapatite, hemostatic sponge) was placed in it. The flap is put in place, the wound is sutured with catgut sutures. A pressure bandage was applied.

The patient is unable to work from ________ to ______, sick leave No. _________ issued. Drug therapy was prescribed (specify which one).

Retention cyst of the oral mucosa

Complaints about the formation of a spherical shape in the mucous membrane of the lower lip. Past and concomitant diseases: influenza, tonsillitis.

History of the disease. About 3 months ago, while eating, the patient bit his lower lip. A few days later, I noticed the appearance of a small formation in the thickness of the lip, which gradually increases, does not hurt, but interferes with eating. Has addressed to the doctor.

local changes. During external examination, the configuration of the face was not changed. Regional lymph nodes are not palpable. Opening of the mouth is free, painless. In the oral cavity: the mucous membrane is pale pink in color, sufficiently moistened. On the inner surface of the lower lip on the right, a rounded neoplasm with a diameter of 0.7 cm is determined, which differs in color from the surrounding mucous membrane. On bimanual palpation in the thickness of the lower lip, a rounded shape, formation, soft-elastic consistency, painless, movable, is determined.

Diagnosis: "retention cyst of the lower lip."

Recording of the operation of removal of the retention cyst of the lower lip

Under infiltration anesthesia (specify anesthetic), two semi-oval converging incisions were made to cut the mucous membrane of the lip. Bluntly and sharply, the retention cyst was isolated from the surrounding tissues, hemostasis. The wound was sutured with catgut sutures. A pressure bandage was applied. The removed preparation was sent for histological examination.

The patient is disabled from _______ to ___________, sick leave No. ______ issued. Appearance _____________ for dressing.

Papilloma of the tongue

Complaints about a neoplasm on the tip of the tongue. Past and concomitant diseases: hypertension stage II.

History of the disease. The patient noticed the appearance of a neoplasm on the coccyx of the tongue about 3 months ago, when a bridge was made at 43, 33. He notes the gradual growth of the neoplasm.

local changes. During external examination, no violation of the configuration of the face was noted. Regional lymph nodes are not palpable. Opening of the mouth is free, painless. In the oral cavity: the mucous membrane is pale pink, well moistened. At the tip of the tongue there is a neoplasm 0.5 cm in size, on a narrow stalk. On palpation - soft, painless, mobile. On the mucous membrane of the neoplasm there are fringed outgrowths, barely noticeable upon examination.

Diagnosis: papilloma of the tongue.

Recording the operation of excision of a benign neoplasm (papilloma, fibroma, etc.)

Under infiltration anesthesia (specify the anesthetic), two semi-oval converging incisions were used to excise the neoplasm of the mucous membrane (specify the organ) within healthy tissues up to the muscle layer. The wound was sutured with catgut sutures. The removed neoplasm was sent for histological examination.

The patient is unable to work from ________ to _______, sick leave No. ______ issued. Appearance ________ for dressing.

Radicular cyst of the jaw

Example 11.

Complaints of painless swelling in the region of the upper jaw on the left, raising the upper lip.

Past and concomitant diseases: the patient is practically healthy.

History of the disease. Previously, periodically ill 22, but the patient did not go to the doctor. I noticed swelling about 2 years ago. He noted a gradual increase. Currently, due to a cosmetic defect, he is sent for a consultation to the regional clinical dental clinic.

local changes. On external examination, there is a slight swelling of the upper lip on the left. The skin is under swelling of the usual color, it gathers well in a fold, on palpation the tissues are soft, painless. Regional lymph nodes are not palpable. Opening of the mouth is free, painless. The base of the lower nasal passage is raised on the left (Gerberian ridge). In the oral cavity: the mucous membrane is pale pink in color, sufficiently moistened. A limited swelling of a semi-oval shape is determined from the vestibular side of the alveolar part of the upper jaw in the region of 11, 21, 22, 23 teeth. The mucous membrane over the swelling is pale with a pronounced vascular pattern. On palpation, the swelling is supple, moderately dense, painless. In the center of it, a mild symptom of a parchment crunch is determined. Crowns of 21, 22 teeth converge, 21 is discolored, its percussion is painless.

Dental formula:

On the radiograph of the alveolar process of the upper jaw, bone tissue rarefaction is determined in the area 11,21,2 2,23 teeth with even and clear rounded contours. The site of rarefaction of bone tissue extends to the bottom of the nose. Conducted EOD: 21, 22 teeth do not respond to currents above 200 mA.

Diagnosis: "radicular cyst of the upper jaw in the area of ​​11,21,22,23 teeth, pushing the bottom of the nose."

Recording a cystectomy operation

The roots of the teeth, in which the apex is resected, are sealed with phosphate-cement in advance during the operation. Under conduction (specify which) and infiltration anesthesia (specify anesthetic), a semi-oval (or trapezoid) incision of the mucous membrane and periosteum to the bone was made. A flap was formed with its base facing the transitional fold in such a way that the future bone wound was somewhat smaller than the soft tissue flap. Peel off the mucoperiosteal flap in the area (indicate which teeth).

A pattern was found in a thinned and swollen compact plate of the bone of the alveolar process, which was expanded in pieces until the anterior wall of the cyst membrane was completely exposed. The shell of the radicular cyst was found and completely isolated, the tops of the roots were resected (indicate the dental formula), which were removed along with the shell of the radicular cyst. The sharp edges of the resulting cavity are smoothed with a milling cutter, they carry out hemostasis and the toilet of the surgical wound and the mucoperiosteal flap. If necessary, the postoperative bone cavity is filled with hemostatic, replacing or optimizing reparative osteogenesis preparations. The flap is put in place, the wound is sutured with catgut sutures. A pressure bandage was applied. The material was sent for histological examination.

The patient is disabled from _______ to __________, sick leave No. __________ issued. Medical therapy prescribed (specify).

Recording of the cystotomy operation

Under conduction (specify which) and infiltration anesthesia (specify anesthetic), a semi-oval incision was made so that it coincided with the boundaries of the bone wound. The mucoperiosteal flap was detached in the area (indicate the formula of the teeth). A bone pattern was found, which was expanded with a bur and wire cutters within the full diameter of the cyst. The cyst shell was exposed and its anterior wall was excised along the border of the bone wound. The causative tooth has been removed. The cyst cavity was washed with 3% hydrogen peroxide solution. Mucosal

the periosteal flap is placed in the cyst cavity, into which an iodoform tampon is tightly inserted in layers, fixing the flap (or the edge of the mucoperiosteal flap is sutured to the cyst membrane). A pressure bandage was applied. The material was sent for histological examination.

The patient is unable to work from _______ to ______, sick leave No. ______ issued. Medical therapy was prescribed (specify which one). Appearance _________ for dressing.