保存适当的牙科记录。

Wilhemina Leeuw
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引用次数: 0

摘要

牙医的法律责任被称为“护理标准”,它要求行使其他谨慎的牙医在面对同样的病人护理情况时所表现出的技能和护理程度。保存良好的牙科记录的主要目的是为了保持护理的连续性。勤勉和完整的文件和图表程序是履行护理标准的必要条件。其次,因为牙科记录被认为是法律文件,它们通过确定所提供服务的细节来帮助保护牙医和/或病人的利益。今天的病人比以往任何时候都受过更好的教育,也更自信,牙医必须装备好保护自己免受医疗事故索赔。每一份记录都必须像被传唤到法庭并由律师、法官或陪审团仔细审查一样处理。完整、准确、客观和诚实的记录是防止可能出现的任何临床和/或法律问题的唯一途径。大多数医疗和牙科事故索赔源于与牙医的不利互动,而不是由于治疗结果不佳。透过实施本课程所提及的建议,牙科保健专业人员可以将与提供牙科保健相关的法律风险降至最低,并促进患者对其完整记录的权利和特权有更深入的了解。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Maintaining proper dental records.

Referred to as Standard of Care, the legal duty of a dentist requires exercising the degree of skill and care that would be exhibited by other prudent dentists faced with the same patient-care situation. Primarily, the goal of keeping good dental records is to maintain continuity of care. Diligent and complete documentation and charting procedures are essential to fulfilling the Standard of Care. Secondly, because dental records are considered legal documents they help protect the interest of the dentist and/or the patient by establishing the details of the services rendered. Patients today are better educated and more assertive than ever before and dentists must be equipped to protect themselves against malpractice claims. Every record component must be handled as if it could be summoned to a court room and scrutinized by an attorney, judge or jury. Complete, accurate, objective and honest entries in a patient record are the only way to defend against any clinical and/or legal problems that might arise. Most medical and dental malpractice claims arise from an unfavorable interaction with the dentist and not from a poor treatment outcome. By implementing the suggestions mentioned in this course, dental health care professionals can minimize the legal risks associated with the delivery of dental care to promote greater understanding for patients of their rights and privileges to their complete record.

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