It is often ironically said that most of the time Dentist’s forget about patients but a dental record always remembers!
A dental record or document is a very significant health record. The dental record is an official record that contains all the detailed information like clinical findings, investigations required, diagnostic notes and treatment planning, all the communication with the patient, and financial details. In fact, it’s a legal binding on every Dentist to maintain and preserve all the information related to dental care rendered to the patients. Thus, the dental document provides indispensable oral health data which determines quality dental care.
What is a dental record?
Earlier a dental document was in the form of paper format but now with increasing digitization there is an upward trend of having an electronic dental record. A dental record is a document that comprises of patient’s detail medical and dental history, chief complaint of patient, diagnosis and treatment plan for same, informed consent and fee estimates. The medical history section should contain details regarding past and present medical ailments, medications which the patient is taking, allergies if any, major hospitalization/surgery recently or in the past.
Dental history should include all the dental treatments of the patient. Covid history has now become more important than ever before in dentistry as we are aware of the long-term consequences of covid infection include mucormycosis. Informed consent is a vital part of the dental document and should be duly signed by the patient which indicates that the patient is aware of his/her dental treatment, dental materials, anesthetics used and is giving permission for the necessary procedure. A dental record also includes dental radiographs, clinical photographs and study models.
General guidelines for maintaining dental records
The Dentist has an ethical, professional, and legal binding to maintain a dental health record of the patient. The dental record should be well-organized, legitimate, detailed, easy to access, and understandable. All the entries in the dental document should be clearly dated. This includes the treatment provided, follow-up visits as well as the fee schedule. A dental record including the radiographs, photographs, study casts should be maintained at least for 10 years.
In case of a minor patient, the record should be maintained for 10 years from the time the patient turns 18 years of age. A dental record is an important document and the Dentist should make sure it is tamperproof! All the electronic dental documents should be stored separately in secured premises. The dental document consists of sensitive information and it is the responsibility of the Dentist to maintain its utmost confidentiality and privacy.
What are the advantages of dental records retention?
Dental documents are a fundamental part of dental practice and are an essential skill for practitioners to maintain them in a good state. There are several advantages of retaining dental records like-
- Dental records serve as a savior for the Dentists in many medico-legal cases.
- Dental records help to provide a clean cheat in malpractice and false insurance claim cases.
- Dental document aids in research by providing valuable data.
- The dental records are like a back-bone in many forensic odontology related cases.
Legal aspects related to dental record keeping
The dental practice norms, doctor-patient relationship and precise record-keeping is little different in India than in western countries. In India, most of these things work on faith and trust! Especially the illiterate population who are not even aware of the paperwork related to dental treatment and its importance. A study conducted by dental institute in Rajasthan, India reported that only 38% of the Dentists maintained dental records! The remaining 62% did not maintain any dental record but only agreed that they are important from a medicolegal point of view! Surprising! Well, it only shows the ignorance amongst the dental fraternity.
But what does the law say? Under Article 51 A(h) of the Constitution of India, there is a moral obligation on the doctor (Dentist), and a legal duty, to maintain and preserve medical, medicolegal, and legal documents (dental record) in the best interests of social and professional justice. Under section 17-A of The Dentists Act, 1948 there are several advantages for a Dentist for good record keeping in order to maintain professional dignity and respect. There is no specific clause by The Dental Council of India on dental documentation but the Indian Dental Association encourages Dentists to maintain a long-term dental record.
Role of dental documents in Forensic Odontology
A dental record is an official health record of a patient where details related to the patient’s treatment and all the communication is mentioned. The forensic odontology branch is growing rapidly. And the role played by dental documents in forensic cases is of paramount importance. A mere dental document speaks a lot on behalf of the deceased body. Hence, serves as vital evidence.
Forensic dentistry comes into the picture when the remains of a dead body cannot be identified visually or through any other method like fingerprints etc. Teeth are considered as the most surviving part of the human body and hence, aid in the personal identification of patients in cases of natural disasters by comparing post-mortem dental records with antemortem dental records. Dental records are very useful in positive identification of individuals in mass disaster cases like earthquakes, floods, other natural calamities, railway and aviation accidents, wars, terror attacks, extreme murder cases etc. Thus, it is the responsibility of a Dentist to maintain a good and accurate dental record.
- Dental record is a health record consisting of subjective and objective information related to dental patients.
- Every Dentist has the legal obligation of maintaining his/her patient’s authentic dental record.
- A dental document should comprise of patient’s chief complaint, medical and dental history, diagnosis and treatment plan, investigations and informed consent from the patient.
- It is mandatory to maintain a dental record for at least 8-10 years.
- A dental document should be simple, understandable, legitimate, accurate, easy to access and tamperproof.
- A good dental record plays a major role in forensic odontology cases.