Ethical and legal questions as regards filling out dental clinical charts

Abstract

Objective: Evaluate imperfections in filling out dental clinical history charts of patients attended at the “Universidade Estadual de Montes Claros – Unimontes”, in 2005, from the ethical and legal aspects. Method: Descriptive statistical analysis, Pearson’s correlation, Chi-Square test (p<0.05) with Bonferroni correction in a contingency table (p<0.003) tests were performed, and Anova – Tukey (p<0.05) were calculate using SPSS software. This study was conducted using 881 clinical history charts of 19 subjects. Results: The highest percentage of charts concerned Stomatology (12%) and 8 th period of the course (25%). The majority (63.3%) of chartshad fields left blank and in 68% the handwriting was illegible. Unjustifiable erasures were found in 74.7% of charts. The majority of charts (98%) were filled out in ink. The treatment plan was signed by course tutor in 83% of the cases. The term of consent was signed in the 94.9 % of the charts. As regards mistakes, 5.1% of documents had one error; 42% two errors; 23.5% three or more errors (average 1.89(± 0.9); percentile 25%=1; 50%=2 and 75%=2). The difference in the proportion of errors as regards filling out all fields differed statistically among the periods (p<0.05). Conclusion: It was concluded that an alarming number of documents were filled out incorrectly. The worst filling out performance was shown in the 5th, 6th and 7th periods (p<0.05).

Keywords

• medical records
• forensic dentistry
• ethic
• registros médicos
• odontologia legal
• ética