The dental record is an essential tool for the success of dental practice and a legal obligation of the dental surgeon. Far beyond a simple record, it is the document that guarantees patient safety, continuity of treatment, and the legal protection of the professional.
In this Dental Access guide, you will understand why the record is indispensable, what should be included in each entry, and what are the consequences of its absence.
Why are dental records fundamental?
1. Complete and accurate documentation
The record gathers all relevant patient information: medical history, anamnesis, diagnosis, treatment plan, treatment performed, and complementary exams. This complete documentation helps professionals make precise decisions and offer personalized care.
2. Patient safety
The record protects patient safety, preventing treatment errors and ensuring that all information is accessible. In cases of dentist changes or legal proceedings, the record is valuable legal proof.
3. Treatment support
The detailed record of the treatment plan, evolution, and procedures performed assists in the continuity of care. The professional can monitor each stage of the treatment and adjust as necessary.
4. Professional responsibility
The proper completion of the record is a duty of the professional. Everything contained in the record can be requested by the patient or used in legal proceedings.
5. Constant updates
Keeping the record always updated is essential. Record each procedure performed, prescriptions, and treatment evolution after each appointment.
Legal implications of the absence of records
The absence of dental records can have serious consequences. See the main risks:
- ⚠️ Professional responsibility: The lack of adequate records can be considered professional negligence, subjecting the dentist to legal proceedings.
- ⚠️ Proof of care: Without the record, it is difficult to prove that a specific treatment was performed. In case of litigation, the dentist may be questioned about the absence of records.
- ⚠️ Patient rights: The Consumer Protection Code guarantees the right to information. The absence of records can be interpreted as a violation of this right.
- ⚠️ Compensation and moral damages: If a patient suffers damages due to lack of records, they may seek compensation for material and moral damages.
- ⚠️ Loss of professional license: Failure to comply with regulations related to records can result in the loss of the professional license with the CRO.
Frequently Asked Questions
Are dental records mandatory?
Yes. Records are mandatory by determination of the Federal Council of Dentistry (CFO). Every dental surgeon must maintain complete and updated records for each patient seen.
How long should records be kept?
The CFO recommends keeping records for at least 20 years after the last appointment. For underage patients, the period starts from when they reach adulthood. Digital records facilitate secure and long-term storage.
What must obligatorily be included in the record?
Complete patient identification, anamnesis (medical and dental history), diagnosis, treatment plan, clinical evolution, procedures performed with dates, prescriptions, complementary exams, and informed consent form.
Do digital records have legal validity?
Yes, provided they meet the security, integrity, and authenticity requirements of the data. The use of systems with digital signatures and secure backup is recommended to ensure legal validity.
Can the patient request a copy of their record?
Yes. The patient has the right to access their record at any time. The dentist is obliged to provide a copy when requested, in accordance with the Dental Ethics Code and the Consumer Protection Code.
Content prepared by Dr. Maysa Monnerat, Technical Manager at Dental Access.
