PubMed · 3273722
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I R Rubira, C B Rodrigues. [Dental records and notation: general considerations].. https://pubmed.ncbi.nlm.nih.gov/3273722/
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Complaints or claims against dentists by dissatisfied patients usually consist of three parts: the dentist did not perform the treatment as s/he should have done; the dentist did not inform the patient properly about the risks involved with the treatment; the dentist did not keep records. In most cases it is not too difficult for a judge or dental board member, if necessary with the aid of an expert witness, to decide whether the treatment was indeed below standard. The same applies to dentist's record keeping. The recrimination concerning the information given is something else. This deals with the extent of the duty to inform a patient as well as the proof that sufficient information was given. These difficulties do not only appear in court, but also in dental surgeries. This article will focus on the evolution in the jurisprudence concerning the duty to inform patients about risks as well as on the recently changed guidelines of the General Dental Council (GDC) regarding informed consent. Finally some simple tests will show that informing patients about risks does not have to be a risky and time consuming business for the dentist.
The aim of this study was to examine the quality of the ante-(AM) and postmortem (PM) dental data that were submitted for entry into the PLASS data system in Phuket, Thailand, following the Boxing Day (December 26) Tsunami, 2004. The investigators were two forensic odontologists who were part of the New Zealand Disaster Victim Identification team that worked at Wat Yang Yao morgue and at the Information Management Center in Phuket. Our findings underline the usefulness of dental data in human identification, but point to a number of significant sources of error. Of the 78 PM records received, only 68% of radiographs and 49% of photos confirmed the accompanying dental charting. This underlines the value, particularly of photographs of the dental arches, in quality control. It also points to a large error component, which may have been due to inexperience of the operators, fatigue, poor conditions in the temporary morgue, or the problem of tooth-colored fillings. Of the 106 AM records received, 62% were of unacceptable quality and 64% were either not accompanied by radiographs or had poor quality radiographs. These results indicate that AM data collection ideally needs to be collated and checked by a forensically trained dentist(s) in the country of origin.
UNLABELLED: Clinical dental records fulfil a variety of functions. Whilst there is no standard data set for dental records, it is essential that these are contemporaneous--that is, they are 'recorded at the time' A good written record should contain details of the patient's identification data, medical and dental history, clinical examination, diagnosis, treatment plan, reference to consent, and progress notes. This paper covers these aspects in detail, and provides information on how long records should be stored, and who may access clinical records. CLINICAL RELEVANCE: The recording of contemporaneous patient/treatment information is central to treatment planning and good patient care.