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.

Download full-text PDF

Source
http://dx.doi.org/10.17116/stomat202110002112DOI Listing

Publication Analysis

Top Keywords

medical records
8
medical record
8
filling medical
8
medical
7
records
5
[the role
4
dental
4
role dental
4
dental medical
4
records assessment
4

Similar Publications

Background: Health authorities worldwide have invested in digital technologies to establish robust information exchange systems for improving the safety and efficiency of medication management. Nevertheless, inaccurate medication lists and information gaps are common, particularly during care transitions, leading to avoidable harm, inefficiencies, and increased costs. Besides fragmented health care processes, the inconsistent incorporation of patient-driven changes contributes to these problems.

View Article and Find Full Text PDF

Background: Information exchange regarding the scope and content of health studies is becoming increasingly important. Digital methods, including study websites, can facilitate such an exchange.

Objective: This scoping review aimed to describe how digital information exchange occurs between the public and researchers in health studies.

View Article and Find Full Text PDF

Use of Electronic Health Records to Identify Factors Related to Skin Changes in Terminal Patients.

Adv Skin Wound Care

January 2025

Chia-Jung Chan, MS, RN, is Head Nurse, Taipei Medical University Hospital, Taipei, Taiwan. Yeu-Hui Chuang, PhD, RN, is Professor, School of Nursing, College of Nursing, Taipei Medical University, and Researcher, Research Center in Nursing Clinical Practice, Wan Fang Hospital, Taipei Medical University; Tsai-Wei Huang, PhD, RN, is Professor, School of Nursing, College of Nursing. Taipei Medical University, and Researcher, Research Center in Nursing Clinical Practice, Wan Fang Hospital, Taipei Medical University; Made Satya Nugraha Gautama, S.Kep, Ns, is Lecturer, Department of Nursing, Faculty of Medicine, Universitas Pendidikan Ganesha, Bali, Indonesia.

Objective: To investigate the incidence of skin changes at life's end (SCALE) among hospice patients and identify associated factors.

Methods: The authors conducted a retrospective chart review of demographic data, medical history, Braden Scale assessment scores, Charlson Comorbidity Index, symptom records, and medical treatments of patients admitted to a local teaching hospital's hospice unit between May 2019 and April 2021.

Results: Most (79%) of the 300 hospice patients included in the study had cancer.

View Article and Find Full Text PDF

Sex Differences in Early/Unplanned Separation Among US Service Members With a History of Mild Traumatic Brain Injury.

J Head Trauma Rehabil

January 2025

Author Affiliations: Program Executive Office, Defense Healthcare Management Systems, Arlington, Virginia (Ms Wal and Dr Caban); National Center for Collaborative Healthcare Innovation (NCCHI), VA Palo Alto Health Care System, Palo Alto, California (Mr Hoover); Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts (Dr Adams); Veterans Health Administration Rocky Mountain Mental Illness Research Education and Clinical Center, Aurora, Colorado (Drs Adams and Forster); Department of Physical Medicine & Rehabilitation, University of Colorado, Anschutz Medical Campus, Aurora, Colorado (Dr Forster); and Uniformed Services University of the Health Sciences, Graduate School of Nursing, Bethesda, Maryland (Dr Engler).

Objective: To investigate the incidence of early/unplanned (E/U) separations following mild traumatic brain injury (mTBI) and assess whether sex impacts the hazard of separation.

Setting: Military Health System (MHS).

Participants: Active duty service members (N = 75,730) with an initial mTBI diagnosis in military records between January 2011 and January 2018.

View Article and Find Full Text PDF

Background: In recessive dystrophic epidermolysis bullosa (RDEB), complications like oesophageal strictures, hand contractures, cardiomyopathy and cutaneous squamous cell carcinoma (SCC) may develop, necessitating procedures such as oesophageal dilatation (OD), gastrostomy tube placement and hand surgery.

Objectives: To determine prevalence and age of onset of milestone events by RDEB subtype, specifically dysphagia, first OD, first gastrostomy tube, first hand surgery, cardiomyopathy, first SCC and death.

Methods: The Prospective Epidermolysis Bullosa Longitudinal Evaluation Study (PEBLES) is a register study of individuals with RDEB which records comprehensive EB- and non-EB-related health information.

View Article and Find Full Text PDF

Want AI Summaries of new PubMed Abstracts delivered to your In-box?

Enter search terms and have AI summaries delivered each week - change queries or unsubscribe any time!