Importância do prontuário em processos civis envolvendo o cirurgião-dentista

Abstract

The objective of this project is to analyze and discuss the importance of documentation in Dentistry, through a literature review, in addition to proposing recommendations for the elaboration of a safe medical record, once this professional class has been suffering with the increase of lawsuits. For being an important document for both the patient and the professional, the medical records have a discerning sequence to be followed in order to obtain necessary information, such as: screening term, clinical record, anamnesis, clinical examination, treatment plan, evolution and intercurrence in the treatment, prescriptions, medical certificates, declarations and complementary exams. In all this sequence of preparation of the medical record, it must contain the patient’s signature or his or hers guardian. Another important step for the legality of this document is its storage, it must be preserved for at least ten years after its last attendance, and when underage, it must be stored for another ten years after turning 18, either at its physical or digital form. From the development of this work, it can be concluded that the dental record is of great importance, both for the judicial defense and for the patient, when it comes to legal proceedings, in the areas: civil, criminal and ethical, and mainly in Covid-19 times.