Post by asadul1212874 on Feb 28, 2024 3:50:34 GMT -5
Having a good dental clinical record model contributes to the professional's daily clinical life, representing a guiding instrument for care and an important legal document that makes up the patient's medical record. Today's content aims to explain everything that the clinical record needs to contain, with the presentation of a complete guide for you! What is a dental clinical record? Within dentistry, the clinical record is a document in which all patient information must be contained. From identification to the treatment plan and budget, as well as the evolution of the treatment. Therefore, the dental clinical record constitutes a support tool for each service, and must always be updated, as it also serves the function of protecting the professional, serving as evidence in the case of civil, criminal and ethical proceedings. How important is the dental clinical record? In 1992, the Federal Council of Dentistry launched a resolution, in which clinical records began to be contained within the dental record, which must meet clinical, administrative and legal criteria. Furthermore, this document also needs to contribute in case of need to identify corpses.
In this resolution, it is also stipulated that after the last service, the medical record needs to be stored for 10 years and that some information must be in all clinical records, such as patient identification, clinical history, clinical exams, budget, plan and evolution of treatments. , additional exams if necessary. In addition to the clinical record, the medical record must also contain duplicate certificates, prescription books, instructions and consents. Ebook 8 Self Benefits that will revolutionize treatments with Henan Mobile Number List orthodontic aligners in your clinic Get to know the Self concept and understand why all its differences contribute to the orthodontist's success in treatment with aligners. Name* Name * Email* Email * Cell phone* +55 Are you an Orthodontist?* Select I agree to receive communications from Aditek Orthodontics. When providing my data, I am aware of the Privacy Policy guidelines . Download E-book should_not_change Dental clinical record: complete guide Despite the extreme importance of a well-filled dental clinical form, this is not a complex task, especially when the form to be followed is formulated in advance and it is understood that filling it out is part of the treatment as well as other procedures. Therefore, we have prepared a guide to help you build your clinical record.
She may have more or fewer questions, depending on the individuality of each professional, but the items below cannot be missing. Professional identification The full name of the dentists serving the patient must be on each clinical record, as well as the registration number of each professional in the CRO of the service region and the clinic's address. Patient identification The patient's identification must also be detailed in the clinical record, including the full name, General Registry (RG) number, individual registration number (CPF), date of birth, place of birth, nationality, marital status, gender and residential and professional addresses. complete. Information such as blood type, how the patient arrived at the clinic, profession and education can also be interesting in this field. Anamnesis General and personal information about the patient, as well as health condition, medical and dental history, use of medications that may interfere with treatment, presence of allergies, habits and diet.
In this resolution, it is also stipulated that after the last service, the medical record needs to be stored for 10 years and that some information must be in all clinical records, such as patient identification, clinical history, clinical exams, budget, plan and evolution of treatments. , additional exams if necessary. In addition to the clinical record, the medical record must also contain duplicate certificates, prescription books, instructions and consents. Ebook 8 Self Benefits that will revolutionize treatments with Henan Mobile Number List orthodontic aligners in your clinic Get to know the Self concept and understand why all its differences contribute to the orthodontist's success in treatment with aligners. Name* Name * Email* Email * Cell phone* +55 Are you an Orthodontist?* Select I agree to receive communications from Aditek Orthodontics. When providing my data, I am aware of the Privacy Policy guidelines . Download E-book should_not_change Dental clinical record: complete guide Despite the extreme importance of a well-filled dental clinical form, this is not a complex task, especially when the form to be followed is formulated in advance and it is understood that filling it out is part of the treatment as well as other procedures. Therefore, we have prepared a guide to help you build your clinical record.
She may have more or fewer questions, depending on the individuality of each professional, but the items below cannot be missing. Professional identification The full name of the dentists serving the patient must be on each clinical record, as well as the registration number of each professional in the CRO of the service region and the clinic's address. Patient identification The patient's identification must also be detailed in the clinical record, including the full name, General Registry (RG) number, individual registration number (CPF), date of birth, place of birth, nationality, marital status, gender and residential and professional addresses. complete. Information such as blood type, how the patient arrived at the clinic, profession and education can also be interesting in this field. Anamnesis General and personal information about the patient, as well as health condition, medical and dental history, use of medications that may interfere with treatment, presence of allergies, habits and diet.