DENTAL RECORD MAINTENANCE AND ITS APPLICABILITY IN MEDICO-LEGAL SCENARIO: A survey among practicing dentists.

Abstract

Dental record, also referred to patient’s chart, is the detailed documentation of patient’s identity, history of illness, examination, clinical findings, diagnosis, treatment done, payments made and all the other patient related communications that occur in the dental office. It also includes the instruction for home care and the consent to treatment and serves as a means of communication between the   treating dentist and any other doctor who will treat the patient. The main purpose of keeping dental records is to deliver good quality patient care and follow up. Dental records serve as an essential source of information for the patient and the  practitioner especially for medico-legal cases in general            practice. It contains the diagnostic information with regards to the patient that can be beneficial to the dentist as well as legal authorities during forensic investigation.With time, an              increase in the number of crimes (child abuse), disasters and wars has led to the need of identification of the deceased or the victim. Hence antemortem dental records play a crucial role.Documentation and good record keeping is necessary in protecting a dentist against medico-legal claims. In case of a claim, a dentist should gather all the documentation of the patient, should avoid discussing the same and should not tamper with or misplace or destroy any of the patient records. Dentists are now increasingly facing legal challenges from patients who are not satisfied with their treatment. Hence, it is mandatory that dentists should be aware of the medico-legal aspects of the field.⁽⁸⁾ Dentist should be aware of the significance of maintaining an accurate dental record. The accuracy of a record determines the vitality of the dental   practice and its maintenance determines the standard of  clinical practice and indicates skillfulness.Thus, the aim of our study was to assess the knowledge, attitude and practice of maintenance of dental records by the practicing dental professionalsand their significance in medico-legal scenario.