Outpatient card, medical card of a dental patient: what is, sample

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 document flow.

Its correct filling guarantees the preservation of information about a person's health, treatment and its results. A dental patient's medical card 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

An outpatient card is a standardized document that includes basic information about the client, medical history, diagnosis and course of 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 value, which allows you to prove the case in controversial situations.

Legislative base: we understand the orders

Form 043 / y is fixed by Order of the Ministry of Health of the USSR No. 1030. By a letter dated November 30, 2009 from 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 to form 043 / y are undesirable, since in disputable situations, for example, in a lawsuit, the proof will take into account the outpatient card of the dental patient according to the established sample.

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

Content - no encryption

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

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

In the second part of the medical record, the diagnosis and examination details are specified:

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

The third part contains:

• treatment plan;
• prescriptions and recommendations;
• conclusions of other narrow-profile specialists.

Templates of some card pages:

Sample Dental Patient Treatment Plan:

This is what the dentist examination certificate form looks like:

By whom and how it is filled - no one deviates

Forms of a dental card exist in electronic form, which can be printed either directly at the clinic or ordered by a specialized organization. The outpatient card is filled in by the clinic staff.

The passport information in the first part is filled in by the administrator of the dental clinic during the initial visit 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, medical history, therefore, 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 electronically save data on medical interventions, dental treatment and reactions to anesthesia, dates of visits and appointments, results of radiographic surveys. Electronic medical dental records of a patient can be completed along with paper medical records. If the dental clinic conducts electronic document management, this does not cancel its obligation to fill out the form 043 / y in paper form.

What information is entered, what is transferred

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

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

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

Diseases can be noted on a special insert, which is the layout of the teeth in the oral cavity. In case of repeated visits 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 in can be done both by hand and by typewritten method - the printed sheets are glued 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 is admitted.

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

• opinions of dentists from other medical institutions;
• results X-ray examination and data on the degree of exposure during such a survey;
• test results.

Now patients have the opportunity to maintain a personal medical record and communicate with the attending physician using the platform Medical card24. For readers from Ukraine there is similar platform.

Where is it stored, where it can hide

This medical dental card of the patient contains personal health data, their safety is guaranteed by law. At the first contact of the client to dentistry, he signs a consent to the storage, accounting and processing of personal information, his personal data. Only with consent, the storage of such information by the clinic will be considered lawful. The provision of personal data of the patient to other persons is possible only if he has given permission to do so, or in the case of 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 of 04.04.2005 N 734 / MZ-14, it is allowed to issue a card to the patient's hands - 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 familiarize himself with his card. On 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 card the patient in the arms - the clinic that receives the patient will itself request documentation from the clinic serving the patient previously. The transfer of the patient's hospital card is carried out by the clinic's management within three days.