Evaluation of medical records maintenance quality in dental medical organizations of Kazan

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Abstract


Aim. Improvement of the quality control of dental medical organizations when diagnosing dentoalveolar anomalies and deformities.

Methods. A retrospective analysis of an orthodontic patient’s medical record maintenance at the dental clinics of Kazan.

Results. Only 30.7% of all the verified documentation were established to be most thoroughly and correctly filled. Information about the obligatory medical insurance policy was indicated only in 2 cards out of all the verified documentation. In all orthodontic patient medical records the fringe benefit category code was absent. The name of the insurance organization in which a patient was unsured, was available only in 2.3% of the cards. Patient’s passport data were available only in 14 (15.9%) cards, and the type of payment for services was registered only in 38 (43.2%). The diagnosis established by a referring medical organization was indicated only in 7 (8%) of the records. When examining the dental rows of patients, their dimensions and apical bases of the jaws, the shape of the dentition were indicated in 40.9% of the documentation. The contact of adjacent teeth was described in 36.4% of all cases, presence of diastema between the upper jaw incisors was represented in 30.7% of the medical charts of orthodontic patients. The diastema between the lower jaw incisors was reflected in 25 (28.4%) medical charts of orthodontic patients. Based on the doctor’s notes in the medical records, it is difficult to understand whether the whole necessary list of diagnostic measures had been performed to the patient in order to confirm this or that orthodontic pathology. Such filling of the medical chart of orthodontic patient at times makes the experts doubt in the correctness of diagnosis of a certain patient.

Conclusion. Doctors-orthodontists do not pay enough attention to the collection of anamnesis of the disease, evaluation of the nature of complaints, as well as use of basic and additional methods of patient examination.


A K Lapina

Author for correspondence.
rinat.saleev@gmail.com
Central Research Institute of Dental and Maxillofacial Surgery Moscow, Russia

R A Saleev

rinat.saleev@gmail.com
Kazan State Medical University Kazan, Russia

V D Vagner

rinat.saleev@gmail.com
Central Research Institute of Dental and Maxillofacial Surgery Moscow, Russia

G T Saleeva

rinat.saleev@gmail.com
Kazan State Medical University Kazan, Russia

L E Smirnova

rinat.saleev@gmail.com
Central Research Institute of Dental and Maxillofacial Surgery Moscow, Russia

F F Mindubaeva

rinat.saleev@gmail.com
Dental polyclinic №5 Kazan, Russia

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© 2018 Lapina A.K., Saleev R.A., Vagner V.D., Saleeva G.T., Smirnova L.E., Mindubaeva F.F.

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