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保存恰当的牙科记录。

Maintaining proper dental records.

作者信息

Bernoni Luisa, Leeuw Wilhemina

机构信息

Marathon Consulting Services, Inc, USA.

出版信息

Dent Assist. 2008 May-Jun;77(3):6-8, 10, 12 passim; quiz 16-7.

PMID:18630845
Abstract

Patients today are better educated and more assertive than ever before, and dentists must be equipped to protect themselves against malpractice claims. Handle every record as if it could be summoned to a courtroom and scrutinized by an attorney, judge, or jury. Complete, accurate, objective, and honest patient records are the only way to defend against any clinical and/or legal problems that might arise. By implementing the suggestions mentioned in this course, dental team members can minimize the legal risks associated with the delivery of dental care and hopefully promote greater patient understanding of their rights and privileges to their record.

摘要

如今的患者比以往任何时候都受过更好的教育,也更有主见,牙医必须做好准备以防范医疗事故索赔。对待每一份记录都要像它可能会被传唤到法庭并受到律师、法官或陪审团的审查一样。完整、准确、客观和诚实的患者记录是抵御任何可能出现的临床和/或法律问题的唯一方法。通过实施本课程中提到的建议,牙科团队成员可以将与提供牙科护理相关的法律风险降至最低,并有望促进患者更好地理解他们对自己记录的权利和特权。

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Audit of dental record-keeping at a university dental hospital.某大学牙医院的牙科病历记录审计。
Health SA. 2023 Dec 20;28:2442. doi: 10.4102/hsag.v28i0.2442. eCollection 2023.