Recommendations for students on filling out a medical record of a dental patient with defects in hard dental tissues at the Department of Orthopedic Dentistry. Algorithm for issuing a "medical record of a dental patient" Patient card in stomatol

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 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.

Health information should include important parameters like the presence of allergies, blood type and Rh factor, chronic diseases internal organs, existing head injuries, currently taking medications, etc. 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, dental card form 043 y 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 the lapse of 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.

AT THE DEPARTMENT OF ORTHOPEDIC DENTISTRY

Medical card 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.

Medical card (outpatient card or medical history) – binding document medical outpatient reception, performing the following functions:

is a plan for a thorough examination of the patient;

Count « Allergological history» the patient is asked if there have been any allergic reactions to medical preparations, facilities household chemicals, food products and others, whether anesthesia was previously used, and whether any complications were noted after its implementation.

For diagnostics pathological condition of the dentoalveolar system, the most thorough study should be carried out 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 must be given:

signs of a change in proportions - a decrease in height lower section face, which may be due to significant destruction a large number 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. Opening the mouth in in full. 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 alternately (from right to left to upper jaw and from left to right - on the bottom) quadrants (segments) of the jaws and each tooth of the jaw are numbered. 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; WITH- 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 of the carious cavity small sizes, probing the cavity is painless.

13 - noted complete absence crown part of the tooth, the root protrudes 0.5-1.0 mm above the gum level, the root walls are of sufficient thickness, dense, without pigmentation, the root is stable, percussion is painless, the marginal gum is without signs of inflammation, it 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 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 anterior teeth overlap lower teeth 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 the X-ray images 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 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, a focus of rarefaction 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 in only after complete examination patient.

When making a diagnosis, it is necessary to highlight:

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

· accompanying illnesses dental;

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, allocate morphological changes dentoalveolar system indicating 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 lengthening 1 degree P-a forms in the area of ​​16 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 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 lengthening of the 1st degree of the P-a form in the area of ​​the 16th tooth.

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 lower jaw dentition», "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-shape 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.

IN 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.

IN concomitant somatic diagnosis are celebrated somatic diseases cardiovascular, endocrine, nervous systems, respiratory organs, gastrointestinal tract and 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 are common(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. Recommended professional hygiene oral cavity."

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 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 – metal-ceramic 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, followed by its 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 metal-ceramic crown with preliminary preparation of the root canal for a cast stump pin tab (by 2/3 of the length unsealing).

3. Restore the anatomical shape of the crown part of the 11th tooth with a cast stump pin tab and a ceramic-metal 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 metal-ceramic 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 best method treatment in this clinical situation, 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 "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 orthopedic treatment defects in hard tissues of 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 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.

^ CARIES IN THE SPOT STAGE or carious demineralization

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

EXAMINATION:

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

^

The goal of treatment is to stabilize the carious process.

Cleansing of the affected surface of the enamel prophylactic paste"Radent";

Treatment of spots localized in areas that are not visible when smiling with Saforide (due to possible staining of teeth);

Treatment of spots localized in areas visible when smiling with the preparation "Stangard", fluorine varnish - "Composil";

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

1) the disappearance of enamel stains

2) restore the gloss of the enamel surface in the affected area.
^

II. SURFACE CARIES

EXAMINATION:

inspection, probing, staining with "Caries Detector".

^

Cleansing the surface of the teeth using Radent paste;

Spots Brown with a rough surface are subject to preparation and sealing. In this case, filling materials are used: "Citrix", "Cimex", - "AMSO", "Lyziks", "Clearfil".

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

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

In case of a superficial lesion in the area of ​​the fissure, it is necessary to treat the surface with Saforide, Composil preparations and carry out dynamic monitoring during repeated examinations every 3 months.

With positive dynamics, seal the fissures with the Titmate sealant.

Requirements for the results of treatment:

Absence of recurrent caries at the border of "tooth tissue - filling";

Stabilization of the process in the area of ​​fissures.
^

III. MEDIUM CARIES

EXAMINATION:

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

^ CHARACTERISTICS OF MEDICAL MEASURES:

Anesthesia (and filtration, conduction, etc.)

Surface cleaning with Radent paste;

cavity preparation with removal of necrotic and pigmented tissues;

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

When filling the material "Citrix" there is no need to apply a gasket and etching;

Imposition of filling material "Clerafil", "Lyziks".

Requirements for the results of treatment:

Absence hypersensitivity on temperature, mechanical and chemical irritants;

^

IV. DEEP CARIES

EXAMINATION:

questioning, examination, instrumental examination, electroodontodiagnostics, temperature test, differential diagnosis with medium caries, with chronic forms of complicated caries.

^ CHARACTERISTICS OF MEDICAL MEASURES.

In case of difficulties in diagnosis - the imposition of a diagnostic seal.

Carrying out anesthesia

Removal of overhanging enamel and softened dentin

overlay medical pads"Cimex", "Lika", "Liner Bond".

Imposition of a temporary bandage with the material "Cimex".

Evaluation of the preparation quality by the "Caries Detector";

With the diagnosis of "Deep caries":

Conducting anesthesia;

Carrying out the preparation;

Checking the quality of the preparation with the "Caries Detector";

The imposition of medical pads from the materials "Lika", "Cimex", "Liner Bond";

Applying an insulating gasket "Cimex", "Lika";

Dentin protection - varnishes or gaskets "Composil", "Cimex", "Lika";

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

Application of filling material "Cntrix"

Requirements for the results of treatment:

No hypersensitivity

Absence of recurrent caries;

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

V. PREVENTIVE SEALING OF DENTAL FISSURES

SURVEY

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

^ EVENT DESCRIPTION

Fissure cleansing with Radent paste;

Fissure sealing with Titmate sealant or treatment with Saforide.

Requirements for sealing results:

No carious lesions of fissures.

^ VI. COMPLICATIONS OF CARIES

VI. I Pulpitis

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

EXAMINATION:

questioning, examination, instrumental examination, electroodontodiagnostics, temperature test, X-ray examination.

^ CHARACTERISTICS OF MEDICAL MEASURES:

Anesthesia

Pulp removal under anesthesia or with preliminary application of devitalizing agents: arsenic paste;

Mechanical and drug treatment of root canals with the use of sodium hypochlorite solution "Neocletzner Sikain";

Root canal filling with Vitapex paste and other types of pastes with gutta-percha;

The imposition of an insulating gasket;

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

Requirements for the results of treatment:

The cessation of pain;

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

VI. II^ Apical periodontitis

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

EXAMINATION:

questioning, examination, instrumental examination, X-ray examination.

^ CHARACTERISTICS OF THERAPEUTIC MEASURES IN THE CONSERVATIVE TREATMENT OF APICAL PERIODONTITIS:

In the acute period - anesthesia

Preparation and opening of the tooth cavity;

Removal of the contents of the root canal and exudate with abundant washing with antiseptic solutions;

Mechanical treatment of the root canal using EDTA;

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

After stopping the acute process and in the presence of a chronic process in the presence of zones of periapical bone tissue destruction, temporary root canal obturation should be applied using osteotropic preparations: "Iodo-glycol paste".

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

Obturation of the root canal with the use of material "Vitapeks" if necessary - in combination with gutta-percha;

The imposition of an insulating gasket "Cimex";

Placement of a permanent filling.

Requirements for the results of treatment:

The cessation of pain;

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

^ Superficial caries

There are no complaints. Came in for a dental cleaning. Objectively: a carious cavity on the medial surface of the 16th tooth is located in the center of an extensive chalky spot, within the enamel.

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

Objectively: a carious cavity on the masticatory surface within the enamel, probing is painless; EOD=3 uA.

Diagnosis: superficial caries of the 16th tooth.

Treatment: preparation of a carious cavity, drug treatment with 3% sodium hypochlorite solution, filling from KPM Valux plus.

^

Medium caries

Treatment: preparation of a carious cavity, drug treatment with 3% sodium hypochlorite solution, filling from KPM Valux plus.

Complaints of short-term pain when eating sweet food.

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

Diagnosis: average caries of the 27th tooth.

Treatment: preparation of a carious cavity, drug treatment with 3% sodium hypochlorite solution, filling from KPM Valux plus.

Complaints of short-term pain when eating.

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

Diagnosis: average caries of the 27th tooth.

Treatment: preparation of a carious cavity, drug treatment with 3% sodium hypochlorite solution, filling from KPM Valux plus.
^

deep caries

Complaints of short-term pain from temperature stimuli.

Objectively: on the chewing surface of the 46th tooth there is a deep

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

Diagnosis: deep caries 46 teeth.

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

Complaints of pain in the 46th tooth when eating.

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

Diagnosis: deep caries of 46 tooth.

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

PULPITS

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

Diagnosis: acute focal pulpitis of the 18th tooth.

Treatment: under infiltration anesthesia Sol. Ultracaini 2%-1.7 ml, a carious cavity was prepared, medicated with 3% sodium hypochlorite on the bottom, calcium hydroxide (Dycal), a gasket (Dyract), a filling from CPM Valux plus.

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

Acute diffuse pulpitis

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

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

On the radiograph dated May 16, 2005, the root canals of the 26th tooth were sealed to the physiological tops. Filling from KPM Herculite XRV.

Complaints about a sharp paroxysmal, long-lasting pain from a hot temperature stimulus. Cold pain The tooth has not hurt before.

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

Diagnosis: acute diffuse pulpitis of the 26th tooth.

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

On the radiograph dated May 17, 2005. the root canals of the 26th tooth were sealed to the physiological tops. Filling from KPM Herculite XRV.

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

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

Diagnosis: acute diffuse pulpitis of the 26th tooth.

Treatment: under infiltration anesthesia Sol. Ultracaini 2%-1.7 ml, the filling was removed, the tooth cavity was opened, deep amputation of the coronal pulp and extirpation of the root pulp, expansion of the root canals and drug treatment with 3% sodium hypochlorite solution, root canal filling AN-26. Temporary filling. Direction for control radiography. On the radiograph dated May 18, 2005. the root canals of the 26th tooth were sealed to the physiological tops. Filling from KPM Herculite XRV.

Chronic fibrous pulpitis

There are no complaints.

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

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

On the radiograph dated May 19, 2005, the root canals of the 26 tooth were sealed to the physiological tops. Filling from KPM Herculite XRV.

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

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

Diagnosis: chronic fibrous pulpitis of the 26th tooth.

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

On the radiograph dated May 20, 2005, the root canals of the 26th tooth were sealed to the physiological tops. Filling from KPM Valux plus.

Complaints of pain during meals at contrasting temperatures.

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

Diagnosis: chronic fibrous pulpitis of the 26th tooth.

On the radiograph dated May 21, 2005, the root canals of the 26 tooth were sealed to the physiological tops. Filling from KPM Herculite XRV.

Complaints of aching pain during meals of contrasting temperatures and the transition of their cold room to a warm one.

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

Diagnosis: chronic fibrous pulpitis of the 26th tooth.

Treatment: under tuberal anesthesia Sol. Lidocaini 2%-4.0, the carious cavity was prepared, deep amputation of the coronal pulp and extirpation of the root pulp, mechanical expansion of the root canals, drug treatment with 3% sodium hypochlorite solution, and root canal filling AN-26. Temporary filling. Direction for control radiography.

OPTIONS FOR RECORDING THE HISTORY OF PATIENTS WHO ARE INDICATED TOOTH EXTRACTION 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 The lymph nodes 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 chronic periodontitis 27 teeth".

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.

E) Under infraorbital 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.
^

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 analgia, but the pain increased, 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"

Example 4

Swelling complaints lower lip and chin, extending to the upper section 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 is determined in this area and positive symptom fluctuations. 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

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

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

The patient is disabled from _______ to _________, issued sick leave No. ______. 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 band has been inserted into the wound (or the wound has been drained with a rubber band)

Example 5

Complaints of pain in the area hard palate on the left of a pulsating character 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 stage, cardiosclerosis.

local changes. On 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 its center. 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 flap triangular shape within the entire infiltrate, pus was obtained. The wound was drained with a rubber strip. Appointed drug therapy(specify which).

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

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

4.1.Medical card of a dental patient

(account form No. 043/y)

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 section "laboratory studies" the results of the applied additional necessary research conducted according to indications to clarify the diagnosis.

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.

Completes her "episode" ( short description results of treatment) and practical recommendations (manuals) 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 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.

Second section - data objective research. 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.

Third section - a common part. It consists of:

survey plan;

treatment plan;

features of treatment;

records of consultations, consultations;

clarified wording clinical diagnoses and so on.

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. Among the typical mistakes made when maintaining outpatient cards in dental practice, include the following:

• 
  careless filling 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 examination of the patient (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 comes into conflict with the doctor.

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 ______________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Bite ________________________________________________________________________

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

_______________________________________________________________________________

_______________________________________________________________________________

X-ray, laboratory data _______________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________
Page 3 f. No. 043/y

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Instructions ___________________________________________________________________

_______________________________________________________________________________

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

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Page 5 f. No. 043/y

4.2. Dentist's daily record sheet

(account form No. 037 / y)

"Daily record sheet of the work of a doctor - dentist (dentist) of a dental clinic, department, office" is filled out daily by doctors - dentists and dentists, leading outpatient therapeutic, surgical and mixed appointments in medical institutions of all types, providing dental care adults, teenagers 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 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 work of the doctor are 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. Logbook preventive examinations 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 is used and conventions. 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 sheet of daily records 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.

main primary medical document, serving to fill in the column of the diary, is the Leaflet of the daily record of the work of the 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 medical organization(another 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 registry 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 founding 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. Names allowed medicines 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.