[Analysis of medical records as an element of quality control and safety of medical activities]. / Analiz meditsinskoi dokumentatsii kak element kontrolya kachestva i bezopasnosti meditsinskoi deyatel'nosti.

ABSTRACT

OBJECTIVE: Studying the issue of quality control and safety of medical activities. MATERIAL AND METHODS: The analysis of domestic literature on the quality of filling out medical documentation has been carried out. RESULTS: A dental patient's medical record (ICSD) is not only the most important legal document, but also a certain indicator of the level of professional competence of a dentist. To find out all sorts of reasons that led to professional errors and adverse consequences after the provision of dental care, a thorough study and general analysis of medical documentation is of great importance, the maintenance and correct execution of which is also necessary for solving a number of other, including legal issues. The most common drawbacks in the design of a dental patient's medical record have been identified, which indicates a decrease in the quality of medical care provided to patients. CONCLUSION: At the moment, there are still unresolved issues related to complete completion of medical documentation. When analyzing the literature, we did not find a purposeful study of the medical history of a dental patient during surgical treatment, which requires further research.