Quality in filling out clinical records by students of a Brazilian Dentistry school

• Autor(a) principal: Rocha, Lorena Castro
• Data de Publicação: 2023
• Outros Autores: Assunção, Cristiane Meira, Severino, Larissa de Moura, Abreu, Lucas Guimarães, Bendo, Cristiane Baccin, Auad, Sheyla Márcia
• Tipo de documento: Artigo
• Idioma: por; eng
• Título da fonte: Revista da ABENO (Online)
• Texto Completo: https://revabeno.emnuvens.com.br/revabeno/article/view/2113
• topic: Prontuários; Administração de Serviços de Saúde; Análise de dados; Educação em Odontologia; Registros Odontológicos; Fichas clínicas; Administración de Servicios de Salud; Análisis de datos; Educación en Odontología; Registros odontológicos; Records; Health Services Administration; Data analysis; Dental Education; Dental Records

The dental record is an important medical and legal document for the proper registration of the services provided by the dental professional and it is essential for better longitudinal monitoring of the patients' oral health condition. The skills necessary for its adequate completion should be developed by students from the start of their clinical practice in professional training centers. This study evaluated the quality of filling out dental clinical records by students from different stages of clinical practice at the Pediatric Dentistry clinic, Dentistry School from UFMG (Federal University of Minas Gerais) in Brazil. Data were collected through dental records of patients assisted between the second semester of 2013 and the second semester of 2019. The registration quality was analyzed descriptively and characterized as fully, partially, or not filled out. Then, a bivariate analysis assessed the completion quality by students from third and sixth semesters (p< 0.05). Of the 296 dental records analyzed, none showed adequate completion of all sections. The main failures observed were incomplete data in the free and informed consent form (75%), in the gingival bleeding index (72.9%) and in the oral condition diagnosis (68.6%). Additionally, patient identification was incomplete in 51% of the dental records. There was no statistically significant difference when comparing students from third and sixth semesters. These results highlight failures in filling out dental records, which continued throughout the students' formation. Therefore, they emphasize the need for awareness-raising strategies among students and teachers, aiming at the adequate maintenance of these records due to their ethical, legal, and scientific relevance.