Palat M
J Dent Pract Adm. 1990 Jan-Mar;7(1):16-22.
Records are the backbone of the dentist's defense in any malpractice claim. Cases involving periodontal disease--failure to timely diagnose, failure to adequately treat, and failure to refer--are responsible for a great number of lawsuits against dentists. Since individuals of all ages are susceptible to periodontal disease, all dental records should contain periodontal evaluations data. This article discusses what information should be recorded in order to assist any attorney defending the dentist or, in many instances, how the completeness of such information may deter a plaintiff's attorney from proceeding with a suit. The information recorded should enable the dentist to assess the patient's health, assess the patient's dental status, diagnose any existing periodontal disease, and provide a diagnosis and treatment plan for the patient. In addition, the record must reflect the consent of the patient to the eventual treatment, the progress notes made during treatment, and completion notes at treatment's end. Finally, the dentist must be made aware of the legality of terminating the doctor/patient relationship and the transfer of records. Complete and accurate records can substantiate proper diagnosis and treatment and/or contributor negligence but poor records may be insufficient to protect even an innocent dentist.
记录是牙医在任何医疗事故索赔中辩护的关键。涉及牙周疾病的案件——未能及时诊断、未能充分治疗以及未能及时转诊——引发了大量针对牙医的诉讼。由于各个年龄段的人都易患牙周疾病，所有牙科记录都应包含牙周评估数据。本文讨论了为协助任何为牙医辩护的律师应记录哪些信息，或者在许多情况下，这些信息的完整性如何可能阻止原告律师提起诉讼。所记录的信息应使牙医能够评估患者的健康状况、评估患者的牙齿状况、诊断任何现有的牙周疾病，并为患者提供诊断和治疗计划。此外，记录必须反映患者对最终治疗的同意、治疗期间的病程记录以及治疗结束时的完成记录。最后，牙医必须了解终止医患关系和转移记录的合法性。完整准确的记录可以证实正确的诊断和治疗以及/或认定存在过失，但糟糕的记录可能甚至不足以保护无辜的牙医。
