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[The role of dental medical records in the assessment of the quality of medical care].

S N AndreevaZ M Izmaylova
Published in: Stomatologiia (2021)
The influence of the quality of registration of medical records in the provision of dental care to the possibility of objective evaluation of the quality of treatment in forensic examinations. The structure of complaints that became the basis for 432 patients' appeal to the court, the frequency of occurrence and the qualitative composition of questions to expert doctors are determined. It is proved, that the medical record of a dental patient is one of the main proofs in the judicial process when justifying the position of the parties: 81% of legislative examinations contained questions about compliance with clinical recommendations and treatment standards, and 69% about the presence of defects and shortcomings of treatment. Analysis of the quality 1530 of dental records in various regions of the Russian Federation showed that only 77.8±1.06% of the records contained a detailed description of the course of surgery, a description of additional diagnostic methods was present in 70.6±1.16%, and an informed consent to surgery in 15.3±0.91% of the records. Unqualified filling out of the medical record is currently regarded as poorly provided medical care so it is necessary to change the attitude of dentists to filling out medical documentation.
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