ON THE QUESTION ORTHODONTIC MEDICAL RECORDS COMPLETION WHEN DENTOALVEOLAR ANOMALIES AND DEFORMATIONS DIAGNOSING

Correct registration of primary medical documentation is very important for storage of diagnostic information, the treatment plan, information about the carrying out of medical manipulations for the elimination of dentofacial anomalies, for examination of quality of medical care in conflict situations. Medical card of the orthodontic patient (form 043- 1/у), approved by order of Ministry of Health of the Russian Federation On approval of unified forms of medical records used in medical organizations providing medical care in outpatient conditions and procedures for their filling from 15.12.2014, №834 is the main document of the orthodontist. At the moment, two years after the release of the order, you need to find out whether approved new medical report form in hospitals with orthodontic care, to determine the property of filling as the main instrument used for examination of quality of medical care provided. The article presents the results of the retrospective analysis of medical cards of the patients receiving orthodontic treatment in the dental clinic at Ryazan State Medical University. Found that detailed and properly designed, only 16,0% of medical cards. Orthodontists don't pay enough attention to the medical history, examination of patients, the conduct of clinical trials and the use of special additional methods of examination of patients, such as cephalometry and functional diagnostics.

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Comparison of Administrative Data and Medical Records to Measure the Quality of Medical Care Provided to Vulnerable Older Patients

Medical Care ◽

10.1097/01.mlr.0000196960.12860.de ◽

2006 ◽

Vol 44 (2) ◽

pp. 141-148 ◽

Cited By ~ 29

Author(s):

Catherine H. MacLean ◽

Rachel Louie ◽

Paul G. Shekelle ◽

Carol P. Roth ◽

Debra Saliba ◽

...

Keyword(s):

Medical Care ◽

Administrative Data ◽

Medical Records ◽

Older Patients ◽

Quality Of Medical Care

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Conflict between doctor and patient: legal consequences

South Russian Journal of Therapeutic Practice ◽

10.21886/2712-8156-2021-2-3-118-122 ◽

2021 ◽

Vol 2 (3) ◽

pp. 118-122

Author(s):

I. G. Berezin ◽

Y. B. Samoilova ◽

Y. L. Shepeleva

Keyword(s):

Medical Care ◽

Point Of View ◽

Medical Services ◽

Sources Of Information ◽

Conflict Situations ◽

Quality Of Medical Care ◽

Official Sources ◽

Legal Consequences

The article is devoted to the quality of medical care from the point of view of the legal consequences of conflict situations arising during the provision of medical services. The authors made an attempt to analyze the most typical conflict situations with possible legal consequences of their resolution based on examples from official sources of information.

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The justice as key principle of humanitarian model of quality management of health care system from position of sociology of medicine

Социология медицины ◽

10.17816/1728-2810-2016-15-1-41-47 ◽

2016 ◽

Vol 15 (1) ◽

pp. 41-47

Author(s):

N. G Kaleva ◽

O. F Kalev

Keyword(s):

Health Care ◽

Quality Management ◽

Medical Care ◽

Medical Documentation ◽

Rural Regions ◽

Large Cities ◽

Rural Districts ◽

Sociology Of Medicine ◽

Quality Of Medical Care

The problem of detection, measurement, evaluation and elimination of inequity and injustice related to health continues to be unresolved in all countries. The study was carried out to evaluate situation related to quality of medical care in primary health care at the regional level and to determine means of its amelioration on the basis of humanitarian model of system of quality management from positions of sociology of medicine. The materials of territorial foundation of mandatory medical insurance of the Chelyabinskaia oblast were taken as basis for analysis. The sampling consisted of 54 383 acts of expertise of quality of medical care, including 42 998 expertises of medical care provided by pediatricians and 61 860 by therapists. The design related to type of clinical audit of medical documentation of completed case in polyclinic practice. The significant differences were established concerning rate of defects of quality of medical care in oblast centers, large cities, towns ans rural regions. The phenomenon of sub-optimization of quality of medical care in towns, and rural districts during period of financing increase of health care is established. The results of study testify availability of injustice in issues of health care of population residing in unfavorable social economic conditions. To support justice related to health the concept of humanitarian model of system of management of quality from positions of sociology of medicine was developed.

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Expertise of quality of medical care in general practice

Russian Family Doctor ◽

10.17816/rfd2017316-22 ◽

2017 ◽

Vol 21 (3) ◽

pp. 16-22

Author(s):

Irina E Moiseeva

Keyword(s):

General Practice ◽

Quality Of Care ◽

Medical Care ◽

General Practitioners ◽

Medical Records ◽

Medical Insurance ◽

Family Doctors ◽

Quality Of Medical Care

The article presents some results of the expertise of the quality of medical care by general practitioners (family doctors) in outpatient medical organizations working in the system of obligatory medical insurance. The most common errors in the collection of information, the diagnosis and the treatment, identified during the expertise of the quality of care by the assessment of patient medical records, as well as comments on the often-occurring defects in the preparation of medical records are listed.

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Medical card - a guarantor of social and legal protection of a medical worker and an indicator of the quality of medical care

Kazan medical journal ◽

10.17816/kazmj81577 ◽

1997 ◽

Vol 78 (4) ◽

pp. 304-304

Author(s):

T. F. Safin ◽

F. N. Samigullina ◽

I. F. Khisamutdinov ◽

B. Kh. Kim ◽

G. R. Kadyrov ◽

...

Keyword(s):

Medical Care ◽

Medical Records ◽

Legal Protection ◽

Medical Worker ◽

Medical Activity ◽

Record Keeping ◽

Effective System ◽

Quality Of Medical Care ◽

Constant Improvement

Maintaining medical records is one of the most important responsibilities in the medical activity of medical and preventive institutions, regardless of their departmental affiliation and form of ownership. Constant improvement of the technology of medical care requires a more effective system of medical record keeping. Computing equipment currently used in medical practice makes it possible to introduce new forms of documents that are convenient and easy to process statistically.

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Medical records management in electronic format

Vestnik Roszdravnadzora ◽

10.35576/article_5d651dbc7aa259.48167277 ◽

2019 ◽

Vol 2019 (4) ◽

pp. 77-80

Author(s):

Ирина Серегина ◽

Irina Seregina ◽

Антон Колоколов ◽

Anton Kolokolov

Keyword(s):

Medical Care ◽

Medical Records ◽

Treatment Process ◽

Care Delivery ◽

Records Management ◽

Electronic Document ◽

Electronic Format ◽

Quality Of Medical Care ◽

Document Flow

The article deals with the legal significance of medical records management in the form of electronic document flow. Proper medical records management, which is necessary for the registration of the diagnostic and treatment process at all stages and for control of the quality of medical care delivery, is basis for evaluating of the organization of medical care and quality of its delivery.

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Optimization of internal quality control system of health care for children needing rehabilitation after neuroinfections

Vestnik of Russian military medical Academy ◽

10.17816/brmma12351 ◽

2018 ◽

Vol 20 (3) ◽

pp. 196-198

Author(s):

I G Samoylova

Keyword(s):

Quality Control ◽

Control System ◽

Medical Care ◽

Internal Control ◽

Medical Documentation ◽

Internal Quality ◽

Tier System ◽

Internal Control System ◽

Quality Of Medical Care

The results of the implementation of a three-tier system of internal quality control of medical care for children in need of rehabilitation after neuroinfections are presented. In 2015, a three-tier internal control system was developed at the clinic of the Children’s Research and Clinical Center for Infectious Diseases. The importance of introducing a new approach was determined by the severity of the patients at this clinic. The severity of the condition of children is due to the effects of neuroinfections. In addition, the quality of medical care is an essential element of improving the health care system in modern conditions. After the introduction of this system, the number of examinations carried out at the first level (heads of clinical departments) increased, at the second level (deputy chief physician for medical work and quality of medical care) decreased. The number of detected defects increased, but the quality factor of medical care turned out to be quite high and fell into the group of «insignificant deviations». The main defects are defects in filling in medical documentation and redundancy in laboratory and instrumental research. The leading position in the structure of defects is occupied by defects in filling in medical documentation with a specific weight of 32,4%. With the introduction of a new quality control system, the average length of stay of a patient in the rehabilitation department came close to the one prescribed in medical and economic standards. Revealed quite a large percentage of diagnostic studies that are not included in the medical and economic standards, that is, additional. This fact indicates the need to revise the medical and economic standards in the direction of expansion, taking into account the need. The third level of the internal control system is designed to assess the corrective actions taken as a result of audits at the first two levels of the internal control system. In general, the three-tier system has certainly improved the quality of care.

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