Medical record of a dental patient: rules for registration and storage. Medical record Daily outpatient card of the patient in orthopedic dentistry

OPTIONS FOR RECORDING THE HISTORY OF PATIENTS WHO ARE INDICATED FOR TOOTH EXTRACTION AND OTHER ORTHOPEDIC MANIPULATIONS

Exacerbation of chronic periodontitis

Example 1

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 area of the tops of the roots 27, a slight swelling of the gingival mucosa is determined from the vestibular side, palpation of this area is slightly painful. On radiograph 27, the palatine root was sealed up to the apex, the buccal roots - 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), the removal of ( 8 7 6 | 6 7 8 ), curettage of the hole; hole filled with blood clot.

c) Under infiltration and palatine anesthesia (anesthetics, see entry above, indicate the presence of adrenaline), the removal of ( 5 4 | 4 5 ). 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) (5 4 | 4 5).

e) Under infiltration and incisive anesthesia (anesthetics see above, indicate the presence of adrenaline) 3 2 1 | 1 2 3. 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 of ( 3 2 1 | 1 2 3 ). Curettage of the hole, it is compressed and filled with a blood clot.

Acute purulent periodontitis

Example 2

Complaints of pain in the area of 32, radiating to the ear, pain when biting on 32, a feeling of 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

Example 3

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 in 3 |; 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: 3 | - the crown is destroyed, its percussion is moderately painful, mobility II - III degree. Pus exudes from under the gum margin Transitional fold in the area 4 3 2| swells significantly, painful on palpation, fluctuation is determined.

Diagnosis: "acute purulent periostitis of the upper jaw on the right in the area 4 3 2| »

Example 4

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".

Recording of orthopedic 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 region of 43,42,41.

(indicate the formula of the 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.

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

The date_______________

Complaints: no, for quickly passing pains when eating sweet, cold food in _______ tooth, he applied for the purpose of sanitation.

Anamnesis: ____ the tooth was not previously treated, it was previously treated for caries, the filling fell out (partially), the cavity was noticed on its own, when examined _____ days (week, month) ago, did not seek help.

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

D.S. : Medium caries _______ tooth. Black class _________.

Treatment: Psychological preparation for treatment. Under anesthesia, without anesthesia, preparation of the carious cavity (removal of the filling), drug treatment with 3.25% sodium hypochlorite solution, washing, drying. Grinding. Polishing.

Filling insulation: Vaseline, Aksil, varnish.

B 01 069 06
A 12 07 003
A 16 07

Doctor:____________

Turnout _______ .

A medical card is a mandatory document for every medical institution. It summarizes information about the client's health, being an integral part of the clinic's workflow.

Its correct filling guarantees the preservation of information about human health, treatment and its results. The medical card of a dental patient has important features, so you need to know what it is and how it is filled out.

What is it, what distinguishes it from a regular medical card

The outpatient card is a document of the established form, which includes basic information about the client, history, diagnosis and treatment. This is one of the main primary documents in a medical institution, which allows you to systematize information. It also has an important legal significance, which makes it possible to prove the correctness in controversial situations.

An important feature of the dental medical record and its difference is a highly specialized focus - it reflects the state of a person.

Legislative framework: understanding orders

Form 043 / y is fixed by the Order of the Ministry of Health of the USSR No 1030. By a letter dated 30.11.2009 of the Ministry of Health and Social Development of the Russian Federation, this form is recommended for use by dentists. It is the same for both state dental clinics and commercial ones.

Since form 043 / y is approved at the legislative level, it is a reporting document.

Sample form 043/y:

Modifications of form 043 / y are undesirable, since in disputable situations, for example, in a lawsuit, the outpatient card of a dental patient according to the established model will be taken into account as evidence.

If necessary, information tabs are pasted into the card printed according to the established pattern, which supplement the content without changing the form itself.

Content - no encryption

Form 043 / y provides for three parts. The first contains passport information:

number and date;
Full name, date of birth of the patient;
address;
job title;
the diagnosis of a dentist;
chronic diseases.

The second part of the medical record specifies the diagnosis and details of the examination:

examination by a dentist;
features of the condition of the teeth;
bite features;
laboratory test results and X-ray data.

The third part contains:

prescriptions and recommendations;
conclusions of other highly specialized specialists.

Templates for some of the card pages:

Sample Dental Patient Treatment Plan:

This is what a dental examination form looks like:

Who and how to fill in - no one is rejected

Dental card forms exist in electronic form, which can be printed either directly at the clinic or ordered to be printed in a specialized organization. Filling out the outpatient card is carried out by the employees of the clinic.

The passport information in the first part is filled in by the administrator of the dental clinic during the initial contact of the client, or by the nurse during the initial examination of the dental patient.

The second and third parts are directly related to the diagnosis and treatment regimen, the medical history, so only a dentist has the right to fill them out.

As part of the automation of the process, electronic services are created that allow you to save in electronic form data on medical interventions, on dental treatment and response to anesthesia, dates of visits and appointments, and the results of radiographic examinations. Electronic medical dental patient records can be filled out along with paper medical records. If the dental clinic conducts electronic document management, this does not cancel its obligation to fill out the 043 / y form in paper form.

What information is entered, what is transferred

After the dentist conducts an examination and the results of the tests appear, information is entered in the "diagnosis" column. The date is indicated.

Requirements for the diagnosis: a detailed and descriptive nature of the condition of the teeth and the oral cavity as a whole.

Describing the disease, the doctor specifies the time of appearance of the first signs, course, complaints of the patient, what treatment was carried out and with what result.

Diseases can be noted on a special insert, which is a. At repeated requests of the patient, entries should be made in the diary of the card.

Entries are made in legible handwriting, blots and corrections are excluded. Filling out can be done both by hand and typewritten - printed sheets are pasted into the medical card.

The attending physician records the dates of admission, the course of the disease and the effectiveness of the treatment, prescribed medications, procedures. Common names and abbreviations are used. All relevant information is entered after the patient's admission.

In addition to the required data, the following information can be entered:

conclusions of dentists from other medical institutions;
the results and data on the degree of exposure from such a survey;
test results.

Now patients have the opportunity to maintain a personal medical record and communicate with their doctor using the Medcard24 platform. There is a similar platform for readers from Ukraine.

Where is stored, where can hide

This medical dental card of the patient contains personal data about health, their safety is guaranteed by law. When a client first contacts dentistry, he signs a consent to the storage, recording and processing of personal information, his personal data. Only with consent will the storage of such information by the clinic be considered lawful. Providing the patient's personal data to other persons is possible only if he has given permission for this, or if there is a court order.

The outpatient card of a dental patient is kept in the dental clinic for 5 years, which are calculated from the moment of the last visit of the client. Then it is handed over to the archive.

In the Letter of the Ministry of Health and Social Development of the Russian Federation dated 04.04.2005 N 734 / MZ-14, it is allowed to issue a card to the hands of the patient - but only with the permission of the head physician of the institution. The refusal may be motivated by the fact that this medical documentation is the property of dentistry, as well as a document of strict accountability.

At the same time, the client has the right to receive information about his health. He has the right to see his card. Upon request, he can be provided with extracts and copies containing information about the types of medical intervention, treatment and examination. In this way, the client will be able to receive complete information without taking the medical card outside the threshold of the medical institution.

Sample card statement:

If the patient makes a transfer from one clinic to another under the compulsory medical insurance policy, there is no need to require the issuance of a patient card in hand - the clinic receiving the patient will itself request documentation from the clinic serving the patient earlier. The transfer of the patient's hospital card is carried out by the management of the clinic within three days.

Accounting medical documentation in dentistry and the rules for its maintenance.

4.1.Medical card of the dental patient

(account form No. 043/y)

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

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

In the line "diagnosis" on the title page of the card, the attending physician puts down the final diagnosis after the examination of the patient, the production of the necessary clinical and laboratory studies and their analysis. Subsequent clarification of the diagnosis, expansion or even change of it with the obligatory indication of the date is allowed. The diagnosis should be detailed, descriptive and only for diseases of the teeth and oral cavity.

Under the dental formula, additional data are entered regarding the teeth, bone tissues of the alveolar processes (change in their shape, position, etc., etc.), bite.

In the "laboratory studies" section, the results of the applied additional necessary studies carried out according to indications to clarify the diagnosis are entered.

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

It concludes with an epicrisis (a brief description of the results of treatment) and practical recommendations (instructions) offered by the attending physician.

In a dental clinic, department or office, only one medical record is entered for the patient, in which records are made by all dentists to whom the patient applied. 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 recording all stages of treatment with its own outcome and instructions. For this purpose, it is necessary to take an insert with the same card number entered and attach it to the previously entered one.

With repeated appeals to specialists of any profile in a year or two, it is necessary to take the insert again (the first sheet of the medical record), reflecting the entire status in it. Comparison of these data with the previous ones will make it possible 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 card No. 043 / y 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;

initial diagnosis;

information about past and concomitant diseases;

information about the development of the present (which has become 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.

The second section is the data of an objective study. 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.

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

survey plan;

treatment plan;

features of treatment;

records of consultations, consultations;

clarified formulations of clinical diagnoses, etc.

The information contained in the patient's medical record is of significant legal importance for clarifying the circumstances of the provision of dental services and assessing their quality. Therefore, the entries made in the medical record are valuable information that can serve as one of the main evidence in cases related to the provision of medical care. Despite the obvious legal significance of primary medical documents, many doctors carelessly treat 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 in order to invite him for a second examination to study long-term results;
unacceptable brevity, the use of unaccepted abbreviations in the records, which can cause various errors, up to the provision of inadequate assistance;
untimely record of medical interventions performed (some doctors record treatment events not on the day they were 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 care in previous stages of treatment; for this reason, sometimes unnecessary (and even erroneous) manipulations are carried out;
non-inclusion in the outpatient card of the results of the patient's examination (analyzes, X-ray examination data, etc.), because of which 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 a diseased tooth is not reflected;
the applied methods of treatment are not substantiated;
the moment of completion of treatment is not fixed;
information about the complications that arise during the implementation of certain methods of treatment is not reflected;
corrections, deletions, erasures, additions are allowed, and this, as a rule, is done when the patient has complications or he comes into conflict with the doctor.

OKUD form code ___________

Institution code according to OKPO ______
Medical documentation

Form No. 043/y

Approved by the Ministry of Health of the USSR

04.10.80 No. 1030

name of institution
MEDICAL CARD

dental patient

№ _____________ 19 ... g. ____________
Full Name ________________________________________________________

Gender (M., F.) ______________________ Age ___________________________________

Address _________________________________________________________________________

Profession _____________________________________________________________________

Diagnosis _____________________________________________________________________________

Complaints ________________________________________________________________________

Past and concomitant diseases ______________________________________

_______________________________________________________________________________

Development of the present disease _______________________________________________

_______________________________________________________________________________

For typography!

when creating a document

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

_______________________________________________________________________________

Examination of the oral cavity. Dental condition
Symbols: absent -
- 0, root - R, Caries - C,
Pulpitis - P, periodontitis - Pt,	8	7	6	5	4	3	2	1	1	2	3	4	5	6	7	8
sealed - P,
Periodontal disease - A, mobility - I, II
III (degree), crown - K,
art. tooth - I

_______________________________________________________________________________

Bite ________________________________________________________________________

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

_______________________________________________________________________________

X-ray, laboratory data _______________________________

_______________________________________________________________________________

_______________________________________________________________________________
Page 3 f. No. 043/y

the date	A DIARY with recurring illnesses	Surname of the attending physician

Outcomes of treatment (epicrisis) __________________________________________________

_______________________________________________________________________________

Instructions ___________________________________________________________________

_______________________________________________________________________________

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

_______________________________________________________________________________

the date	A DIARY history, status, diagnosis and treatment at presentation with recurring illnesses	Surname of the attending physician

Page 5 f. No. 043/u

Survey plan	Treatment plan	Consultations

etc. to the bottom of the page

4.2. Dentist's daily record sheet

(account form No. 037 / y)

"Daily record sheet of 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.

"Leaflet" serves to record the work carried out by doctors - dentists and dentists in one day.

Based on the data of the "Sheet", the "Summary sheet" is filled out. Control over the correctness of filling out the "Sheet" and transferring its data to the "Consolidated Statement" is carried out by the head, to whom the doctor is directly subordinate.

When monitoring the correctness of maintaining the "Leaflet", the head compares the diary entries with the medical record of the dental patient (f. N 043 / y).

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

(account form No. 039-2/u-88)

The "Summary" is compiled by a medical statistician or a staff member appointed by the head of the facility. The "Summary sheet" is filled out daily based on the development according to the "List" of the doctor's work (f. N 037 / y-88). At the end of the month in the "Summary Statement" of each doctor is summed up. Table. 7 of the reporting form N 1.

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

In dental clinics, departments, offices that provide assistance only to the adult population or only to children, data on the doctor's work is filled in one "Summary sheet", because. in these cases, the need to differentiate the reception of adults or children is eliminated.

In dental clinics, departments, offices that provide assistance to both adults and children, two "Summary sheets" are kept for each doctor. In one statement, general data is recorded, in the other - data on children.
4.4. Register of preventive examinations of the oral cavity

(account form No. 049-y)

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

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

The working part of the journal consists of 7 columns, on each line, against the name of the examined person, healthy persons who do not need sanitation and 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 the dental formula and symbols are used. In the “sanitized” column, persons are marked who have completely completed the sanitation, 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 / y "Diary of accounting for the work of a dentist."

4.5. Sheet of daily record of the work of a dentist-orthopedist

(recording form No. 037-1/y)

The leaflet of the daily record of the work of an orthopedic dentist is the main primary document reflecting the workload of one working day with a contingent of patients and the volume of treatment and preventive measures.

It is used to fill in the diary of accounting for the work of an orthopedic dentist (form No. 039-4 / y).

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

It is filled in all dental orthopedic institutions (departments) budgetary and self-supporting.

4.6. Diary of accounting for the work of an orthopedic dentist

(account form No. 039-4/y)

The diary is designed 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 in the diary column is the Sheet of daily accounting for the work of an orthopedic dentist (f. No. 037-1 / y).

4.7. Medical card of an orthodontic patient

(account form N 043-1/y)

Registration form N 043-1 / y "Medical record of an orthodontic patient" (hereinafter referred to as the Card) is filled in by a doctor of a medical organization (other organization) providing medical care on an outpatient basis.

The card is filled in for each first contacted patient (ku).

The title page of the Card is filled in at the reception desk of the medical organization when the patient first contacts. The title page of the Card contains the data of the medical organization in accordance with the constituent documents, the number of the Card is indicated - the individual registration number of the Cards established by the medical organization.

The Card 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 visit of the patient (s).

Entries are made in Russian, neatly, 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 record the names of medicinal products for medical use in Latin.
4.8. Diary of accounting for the work of a dentist-orthodontist

(recording form No. 039-3/y)

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

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

The medical record of a dental patient is a document for identifying a patient. The medical card describes the features of the condition and changes in his health.

All data of the medical record are filled in by the doctor and confirmed by the data of instrumental, laboratory and hardware studies. In addition, the medical record reflects all the features and stages of treatment.

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

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

Medical card of a dental patient

As early as October 4, 1980, Form 043 / y was approved by Order of the Ministry of Health of the USSR No. 1030, which was intended specifically for maintaining records of dental patients.

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

The current legislation recommends (but does not oblige) the use of form 043 / y for medical records of dental patients. However, it is most convenient to keep patient records in the appropriate programs for managing dentistry.

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

The medical card of a dental patient is filled out at the first visit of the patient to the dental clinic. Personal data (name, gender, age, and so on) is filled in by a nurse or dental administrator, and the rest of the card is filled out exclusively by the attending physician.

Rules for issuing a medical card for a dental patient by a doctor

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

Each of them should record their stages of treatment on a separate insert and then place them on the card.

Rules for storing medical records

The medical card must always be in, it is not issued to the patient at home. But we recommend that you give the patient a special form with you, which indicates the date of the next visit. You can develop and release it yourself or use one offered by partner companies, such as a toothpaste manufacturer.
Considered a legal document, the card must be kept for 5 years from the day the patient last visited dentistry and a corresponding entry was made on the card. The document is then archived.
The contents of medical records should exclude the possibility of breach of confidentiality and illegal access to them, so it is best to keep them under lock and key.

Informed voluntary consent for dental treatment

Dental services are included in the "List of certain types of medical interventions for which citizens give informed voluntary consent when choosing a doctor and medical organization for receiving primary health care", which was approved on April 23, 2012 by the Ministry of Health and Social Development of the Russian Federation. By signing this document, the patient testifies that he is voluntarily treated in dentistry, he was explained in detail the need for certain procedures, the plan of which is prescribed in his medical record. The client demonstrates an understanding of possible outcomes, existing risks, and alternative treatment options. He is aware of the possible side effects of the planned treatment (pain, discomfort, swelling of the face, sensitivity to cold / heat, etc.). The patient also confirms his understanding that the treatment plan may change in the process.

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

Consent to the processing of personal data

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

All materials were provided by the RaTiKa dental clinic (Yekaterinburg). Text: Elizabeth Gertner

OKUD form code ___________

Institution code according to OKPO ______

Medical documentation

Form No. 043/y

Approved by the Ministry of Health of the USSR

04.10.80 No. 1030

name of institution

MEDICAL CARD

dental patient

No. _____________ 19 ... g. ____________

Full Name ________________________________________________________