A patient`s dental record is both a medical and legal document. According to the American Dental Association, “the dental record also serves to ensure continuity of patient care and is essential in the event of insurance failure,” and “the information contained in the dental record should be primarily clinical in nature.” Rowe described implied consent as follows: “By sitting in the chair of the dental office with his mouth open, a patient implies that he is there for dental treatment” and continued: “In the past, a dentist performed a treatment as he saw fit, which the patient accepted without arguments” [8]. With regard to forensic medicine in the penitentiary system, the main task of the prison doctor and other health personnel is to ensure the health and well-being of prisoners. The 7 essential principles governing the provision of health care in prison include free access to a doctor for each prisoner, equivalence of care, patient consent and confidentiality, preventive care, humanitarian assistance, professional independence and professional competence [5]. In some states, proper maintenance and storage is a prerequisite for a dental license.18 From a legal or risk management perspective, legible and accurate records are always required. Some of these methods (e.g. DISC profiling, etc.) can provide valuable information about different patients` decision-making. You can help the whole team communicate with this patient. These notes or classifications can be included anywhere in the patient`s record, either on paper or electronically.

Some offices may even choose to include it in progress notes or conversation notes, while others may want to do so more discreetly with a sticker/code/abbreviation elsewhere in the folder. Paper documents can take up a lot of space and require dry, secure storage. They should not be left in public places where unauthorized personnel may have access. To save space, documents can be converted to microfilm (or microfiche), which takes up much less space than paper documents. Another option is to opt for a disk storage service. This method can be costly over several years. In dental practices that are considered covered entities, a HIPAA Business Partner Agreement may be required if record retention is outsourced. Diagnostic and/or treatment casts can be photographed and stored in some cases. However, before fully moving into the records of any of these methods, a dentist should consult their own lawyer and professional liability insurance.

Legally, the tort (civil wrongdoing) of negligence against a dentist can only be established if the following elements are present [1]: Before the year 2000, from 1966, Romania was centralized: the Institute of Forensic Medicine was of course located in Bucharest, while in the other major cities of Romania, several branches of the institution were financially and administratively subordinated to the Centre. Today, the national grid system of forensic medicine in Romania has three levels, namely: six independent forensic medicine institutes that coordinate professional activity in several counties, forensic medicine services that solve cases at county level, forensic medicine consultation rooms in major cities. With regard to private practice, under the new 2000 Act, experts have the right to exercise expert advice in private. In other words, we are not able to give the patient official medico-legal documents, but only to explain or advise the question marks of one of the parties or to interpret the results of an autopsy or traumatic examination. The American Medical Association (AMA) and the American Medical Records Association (AMRA) recommend a retention period of 10 years, and the Joint Commission for Accreditation of Healthcare Organizations (JCAHO) states that the retention period should depend on the need to use records for ongoing patient care and for legal, research, or educational purposes. as well as laws and regulations.32 The ADA states: that the retention of records after a patient`s last visit depends on state laws and regulations. contractually agreed upon dental service plans. The ADA recommends checking with your attorney, state dental association, or state dental association for your state`s specific requirements.33 As medical professionals, we should follow the lead of other medical professionals when it comes to our records. The Texas Medical Association article, “What Should Not Be Included in a Medical Record,” states that medical records can be a physician`s “best defense” or enemy against allegations of malpractice, warning that the patient`s record is too often used as a personal diary for interactions with patients and staff.

3 To dispel the doubts of the judge or jury, or in our case, a dental agency, the Texas Medical Association, urges physicians to limit entries in records to information about the care provided and cautions against including the following information: Two doctrines can extend the statute of limitations (SOL): the doctrine of continuous treatment and the doctrine of foreign bodies. Ongoing processing extends the SOL, which is calculated from the last date of processing of the specific issue about which the complaint is filed. For example, if an intervention on tooth n°3 on 01.06.15, then 21/2 years for the measurements of 12.1.17. However, if this procedure is adapted or replaced by tooth No 3 on 12.1.15, the deadline for measurements would be extended by 2 1/2 years from 12.1.15 to 01.06.18. This doctrine applies to adults and will be adapted accordingly for minors. Colorado: All medical records must be retained for all pediatric patients for 7 years after the patient`s last dental visit or 7 years after the patient has reached the age of 18. The Foreign Object Doctrine extends the SOL by 1 year from the date the object was discovered or 1 year from the date on which a reasonably prudent person should have discovered the object. Foreign bodies are inadvertently implanted into a body; That is, a file used in an endodontic procedure or a separate instrument, or a sponge used in a surgical procedure – not items that are intentionally implanted, such as dentures or dental implants.

The foreign body doctrine can be neutralized if the physician informs the patient of the event and documents the foreign body and the conversation with the patient; i.e., a separate endodontic instrument or overworked endodontic filler/sealing material. In an emergency involving children, when no parent or guardian is available, consent may be obtained from the person bringing the child for dental examination or treatment (e.g. teacher, supervisor, etc.). [14]. Patients may request a copy of their record for any purpose; specifically. personal use or transfer to another provider. The original supplier must do so within a reasonable period of time, such as 10 working days; The request must be made in writing and recorded in the minutes. The supplier must always keep the original documents and provide only copies. It is legal to charge for copying records, as most states have a fixed fee for copying pages.