Consideraciones normativas y legales del expediente clínico electrónico en odontología / Normative and legal considerations of the electronic clinical record in odontology

La elaboración del expediente clínico es una actividad rutinaria dentro del consultorio dental, éste es la materialización del acto médico, a tra- vés del cual se registra el estado de salud inicial del paciente, así como toda la información relativa al tratamiento recibido. Desde hace algunos años comenzó a promocionarse el expediente clínico electrónico como una herramienta alternativa y novedosa para elaborar este importante documento; sin embargo, la implementación de esta herramienta electrónica no ha podido lograrse en México, dada la gran cantidad de dudas que los odontólogos tienen respecto al conjunto de leyes y normas que regulan al expediente clínico, lo cual genera renuencia por parte de los odontólogos para utilizar esta modalidad de expediente dentro de su consulta diaria. El objetivo del presente artículo es realizar una revisión de la literatura, así como de las leyes y normas vigentes que regulan el expediente clínico en México para esclarecer así la viabilidad de implementarlo dentro del consultorio dental

The preparation of the electronic medical record is a routine activity in the dental office, this is the materialization of the medical act, through which the initial health status of the patient is recorded, as well as all the information related to the received treatment. A few years ago, the electronic clinical record began to be promoted as a novel alternative tool to prepare this important document, however, the implementation of this electronic tool has not been achieved in Mexico, given the large number of doubts that dentists have regarding the set of laws thar regulate the clinical record, which generates reluctance on the part of dentists to use this record modality within their daily consultation. The aim of this article is to carry out a review of the literature, as well as the current laws that regulate the clinical record in Mexico, in order to clarify the feasibility of implementing it within the dental office

Aspectos legales del consentimiento informado en odontología / Legal aspects of informed consent in dentistry

El consentimiento informado forma parte de los elementos que constituyen el expediente clínico. Por su importancia informativa sobre posibles riesgos y complicaciones inherentes al tratamiento a realizar, su elaboración resulta de vital importancia. Existen numerosas legislaciones y normatividades que regulan este notable documento; sin embargo, resulta alarmante que muchos profesionistas omiten su realización o lo elaboran erróneamente, poniéndolos en riesgo de sufrir problemas legales. Además, es una realidad que el consentimiento informado es un documento mal entendido por la mayoría de los profesionistas, pudiendo incurrir en numerosos errores por desconocimiento. El objetivo del presente artículo es informar al cirujano dentista sobre los verdaderos alcances del consentimiento informado con fundamento en la legislación vigente en México (AU)

Informed consent is part of the elements that make up the clinical record. Due to its informative importance on possible risks and complications inherent to the treatment to be carried out, its preparation is of vital importance. There are numerous laws and regulations that regulate this remarkable document, however, it is alarming that many professionals omit its elaboration or wrongly elaborate it, putting them at risk of suffering legal problems. In addition, it is a reality that informed consent is a document misunderstood by most professionals, and may incur numerous errors due to ignorance. The aim of this article is to inform the dental surgeon about the true scope of informed consent based on current legislation in Mexico (AU)

Odontología forense: en evolución constante / Forensic dentistry: In constant evolution

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Honoring Dental Patients' Privacy Rule Right of Access in the Context of Electronic Health Records.

A person's right to access his or her protected health information is a core feature of the U.S. Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule. If the information is stored electronically, covered entities must be able to provide patients with some type of machine-readable, electronic copy of their data. The aim of this study was to understand how academic dental institutions execute the Privacy Rule's right of access in the context of electronic health records (EHRs). A validated electronic survey was distributed to the clinical deans of 62 U.S. dental schools during a two-month period in 2014. The response rate to the survey was 53.2% (N=33). However, three surveys were partially completed, and of the 30 completed surveys, the 24 respondents who reported using axiUm as the EHR at their dental school clinic were the ones on which the results were based (38.7% of total schools at the time). Of the responses analyzed, 86% agreed that clinical modules should be considered part of a patient's dental record, and all agreed that student teaching-related modules should not. Great variability existed among these clinical deans as to whether administrative and financial modules should be considered part of a patient record. When patients request their records, close to 50% of responding schools provide the information exclusively on paper. This study found variation among dental schools in their implementation of the Privacy Rule right of access, and although all the respondents had adopted EHRs, a large number return records in paper format.

[Orthodontic treatment failure: the advice of a forensic expert]. / Échec d'un traitement orthodontique : les conseils de l'expert judiciaire∗.

If patients consider that their orthodontic treatment is a failure, they can claim compensation from their practitioner. Most often, discontented patients call on their third-party liability insurance when they are covered for "legal expenses protection". The patient's insurance company will then get in touch with the practitioner's insurance firm. Three-quarters of all claims are dealt with by the insurance companies. However, if an agreement cannot be reached or if the practitioner's insurance company manages to establish that he/she is not at fault, the patient can apply to the Tribunal de Grande Instance, the French Regional Court. The judge appoints a forensic expert who will examine the patient and follow a very precise procedure involving a dozen different questions. The advice of the forensic expert is therefore very valuable to orthodontists, in particular regarding their duty to inform patients and the importance of the medical file in order to avoid being held accountable following a course of treatment.

Australian oral health case notes: assessment of forensic relevance and adherence to recording guidelines.

BACKGROUND: Dental case notes record clinical diagnoses and treatments, as well as providing continuity of patient care. They are also used for dento-legal litigation and forensic purposes. Maintaining accurate and comprehensive dental patient records is a dental worker's ethical and legal obligation. METHODS: Australian registered specialist forensic odontologists were surveyed to determine the relevance of recorded case note items for dental identification. A dental case notes sample was assessed for adherence with odontologist nominated forensic value and compiled professional record keeping guidelines of forensic relevance. Frequency of item recording, confidence interval, examiner agreement and statistical significance were determined. RESULTS: Broad agreement existed between forensic odontologists as to which recorded dental items have most forensic relevance. Inclusion frequency of these items in sampled case notes varied widely (e.g. single area radiographic view present in 75%, CI = 65.65-82.50; completed odontogram in 56%, CI = 46.23-65.33). Recording of information specified by professional record keeping guidelines also varied, although overall inclusion was higher than for forensically desired items (e.g. patient's full name in 99%, CI = 94.01 - >99.99; named treating practitioner in 23%, CI = 15.78-32.31). CONCLUSIONS: Many sampled dental case notes lacked details identified as being valuable by forensic specialists and as specified by professional record keeping guidelines.

Importância pericial dos sistemas de notação dental – revisão de literatura / Forensic importance of the dental notation systems – a review

Em algumas circunstâncias, o conhecimento de sistemas de notação dentais utilizados internacionalmente pode ser importante para a avaliação dos documentos odontológicos apresentados. O objetivo desse trabalho é revisar a literatura, exemplificando e descrevendo os principais sistemas,permitindo a sua identificação e compreensão. Com as informações apresentadas será possível atranscrição de prontuários que utilizem sistemas diferentes dos encontrados no Brasil. Devido àsemelhança entre os sistemas e sua utilização restrita aos profissionais da odontologia, recomenda-seque sempre seja avaliado o sistema presente nas documentações como etapa inicial. Também deve serdescrita, de maneira objetiva, qual a notação dental utilizada em laudos e pareceres.

In some circumstances, the knowledge of dental numbering that are in use internationally maybe useful when analyzing dental charts presented. The objective of this study is to review theliterature, to give examples and to describe the main numbering systems, allowing itsidentification and comprehension when necessary. With this information it will be possible toread and transcribe the dental records that present other numbering system than the onesfound in Brazil. Due to similarity between systems, and it’s restrict use by dental professionals, itis recommended that one always analyze the notation system as a first step. In addition, thesystem is in use should be clearly described, when writing forensic reports.

Importância ético-legal e significado das assinaturas do paciente no prontuário odontológico / Legal and ethical importance and patient’s signature significance in dental records

Introdução: O prontuário odontológico é um importante documento na prática clínica, pois é possível arquivar nele informações como diagnóstico; planejamento; evolução do tratamento e exames complementares, e, também porque possui finalidade administrativa e legal. Objetivo: discorrer sobrequem, porque, quando e onde assinar os documentos odontológicos do prontuário, bem como analisar osignificado dessas assinaturas com o intuito de orientar o cirurgião-dentista para atuar ética e legalmente.Material e método: Foram selecionados, por amostra de conveniência, dois Acórdãos que versavam sobrequestionamentos de paciente contra cirurgião-dentista, sendo um do Tribunal de Justiça do estado deMato Grosso do Sul e outro de São Paulo. O conteúdo desses documentos foi analisado qualitativamente,sendo transcritos os trechos de interesse odontolegal. Discussão: Quando acionados judicialmente, oscirurgiões-dentistas não foram capazes de provar, por meio de documentos, as faltas recorrentes dospacientes, a entrega de documentos odontológicos aos pacientes, a realização de instruções erecomendações referente ao tratamento realizado. O valor da assinatura do paciente em qualquerdocumento odontológico pode ser questionado tanto pelo momento e forma de obtenção, quanto deacordo com a sua capacidade civil. Conclusão: o registro detalhado dos procedimentos executadosjuntamente com a assinatura do paciente/responsável é a conduta que melhor respalda o profissional deforma administrativa e legal.

Introduction: The dental record is an important document in clinical practice, because it can be used torecord: diagnostic information; planning; developments in the treatment and complementary tests, andalso because it has administrative and legal purpose. Objective: To discuss who, why, when and where tosign dental records documents and analyze the meaning of these signatures in order to guide the dentistto act ethically and legally. Methods: two judgments that focused on patient inquiries from dentists, one ofthe Court of the State of Mato Grosso do Sul and another in Sao Paulo, were selected by conveniencesample. The content of these documents was qualitatively analyzed, being transcribed excerpts of most interest to Legal Dentistry. Discussion: When the dentists were sued, they were not able to prove, throughdocuments, recurring patients’ absences; handing over documents of dental records to patients; carryingout instructions and recommendations regarding the treatment performed. The value of the patient’ssignature in any dental document can be questioned both concerning the timing and form of obtaining andalso considering their legal capacity. Conclusion: the detailed record of the procedures performed alongwith the signature of the patient or their guard is the conduct that best supports the professionaladministrative and legal manner.