Analysis of medical records as an element of quality control and safety of medical activities

Abstract

Studying the issue of quality control and safety of medical activities. The analysis of domestic literature on the quality of filling out medical documentation has been carried out. 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. 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.