Ethical-legal evaluation of clinical records in Brazilian dentistry courses

Abstract This study analyzes the dental records used in the Brazilian dentistry courses, considering their suitability regarding the ethical guidelines of the legislation in force in the country. All the coordinators of the 220 graduation courses registered on the Federal Council of Dentistry’s website were invited, and 96 (43.6%) accepted to participate in our research. For the collection and analysis of data, we used a structured questionnaire with ethical and legislative questions. Of the total sample, 53.2% presented all the necessary minimum documents, but none of them met all the requirements of patient identification, anamnesis, informed consent form, and odontograms. Moreover, 17.8% fulfilled all the items for planning, and 61.5% had the authorization for the use of data and images. We concluded that these records do not conform to the current legislation and must be updated in order to obtain an improvement in the quality of the information, avoiding administrative, moral and legal problems.