ANALYSIS OF THE QUALITY OF MEDICAL DOCUMENTATION WHEN EVALUATING THE ACTIVITIES OF A DENTAL CLINIC

Abstract

One of the criteria for assessing the quality of medical care is the complete maintenance of medical records. Defects in the preparation of medical documents lead to serious errors, such as incorrect diagnosis, unreasonable choice of diagnostic methods and treatment. To clarify the causes of their occurrence and adverse consequences, the study and analysis of medical records in dental organizations is of no small importance. Properly completed medical documentation serves as the basis for conducting forensic investigations within the framework of a criminal case in case of defects in the provision of medical dental care. The outpatient card of a dental patient is the object of quality control of medical care in dental organizations in the event of conflict situations. Purpose of the study: To analyze the quality control and safety of medical activities and the examination of the quality of medical dental care carried out in the dental clinic of the Military Medical Academy named after. CM. Kirov. Material and methods. During the study, analytical and statistical methods were used. The collection of primary information was carried out on the basis of data from primary medical documentation - 1067 outpatient records of dental patients. Results and condemnation. A statistically significant influence of a doctor’s work experience on the completeness of providing information about patients’ complaints was revealed. Doctors with less experience provide more complete descriptions of patient complaints. Among all complaints, aesthetic ones were most often described; complaints of a morphological and functional nature were noted quite rarely. In the cards of form No. 043/u, in 46.67% there was no information about the bite, the hygiene index was not determined, treatment plans and visit diaries were not filled out correctly. Conclusions. Internal quality assessment helps to detect defects in filling out dental patient outpatient records. The importance of adequate medical record keeping is beyond doubt; the form of the medical record must meet the needs of dentists and contain information that complies with the legal and regulatory framework.