J Dentofacial Anom Orthod
Volume 20, Number 1, 2017
|Number of page(s)||10|
|Published online||06 August 2018|
The medical record
Qualified specialist in ODF [Dentofacial orthopedics], Assistant University Hospitalist Paris 7 –, Hospital practitioner Hôpital Pitié-Salpêtrière
Address for correspondence: Yves Soyer 170, avenue de la République – 91230 Montgeron. E-mail: email@example.com
Accepted: 20 July 2016
A patient medical record in dentistry has several important functions. It is a documentation of the patient’s condition and treatment provided, forecasts and controls, it contains all patient identifiers.
The information contained in the medical record form a working basis for the practitioner and enable to help all healthcare professionals involved in the treatment.
The treating practitioner must be able to produce that documentation to the patient and official bodies who would be entitled to ask as part of a research responsibility in litigation.
Key words: Medical record / documentation / obligations (ethical, legal, HAS [Haute Autorité de Santé] recommendations) / liability / loss of opportunity
© The authors
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