2021, Number 5
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Rev ADM 2021; 78 (5)
Legal considerations on medical charts in dentistry.
Tiol-Carrillo A
Language: Spanish
References: 11
Page: 280-282
PDF size: 171.82 Kb.
ABSTRACT
The clinical file is considered a document of medical and legal importance where the data necessary to record the diagnosis and the treatments performed on each patient are integrated. One of the most important elements within the clinical records are the medical charts, documents through which de dentist reports on the general condition of the patient and the treatments performed appointment after appointment. There are specific laws in Mexico that guide the stomatologist on the minimum necessary components that a medical chart must have, however, one of the most common omissions of dentist is that, due to ignorance, due importance is not given to the preparation of an adequate medical chart, increasing the risk of legal problems. The aim of this article is to analyze the importance of the evolution charts within the clinical records, highlighting their clinical and legal importance.
REFERENCES
Suti Ismawati ND, Supriyanto S, Haksama S, Hadi C. The influence of knowledge and perceptions of doctors on the quality of medical records. J Public Health Res. 2021; 10 (2): 2228.
Carmona-Mejía B, Ponce-Gómez G. Evaluación del expediente clínico integrado y de calidad en pacientes de cirugía programada. Rev CONAMED. 2014; 19 (3): 117-127.
Ramírez RA. Introducción al tema de la documentación del acto médico. Rev CONAMED. 2007; 12 (1): 29-30.
Ley General de Salud. 2021.
NOM-004-SSA3-2012 Del expediente clínico. Diario Oficial de la Federación.
NOM-013-SSA2-2015 Para la prevención y control de enfermedades bucales. Diario Oficial de la Federación.
Reyna-Lara M. Derechos y obligaciones de los usuarios del servicio de salud. Med Int Mex. 2018; 34 (5): 780-791.
Sando KR, Skoy E, Bradley C, Frenzel J, Kirwin J, Urteaga E. Assessment of SOAP note evaluation tools in colleges and schools of pharmacy. Curr Pharm Teach Learn. 2017; 9 (4): 576-584.
Muñoz J. El registro medico orientado por problemas. An Fac Med. 1998; 59 (1): 73-78.
Medrano MJ. Expediente clínico odontológico. Cómo elaborarlo, integrarlo, manejarlo y archivarlo conforme a la normatividad. México: Trillas; 2018. pp. 45-46.
Tiol-Carrillo A. El peritaje odontológico forense. Rev Odont Mex. 2016; 20 (3): 154-158.