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.

摘要 本研究针对巴西牙科学本科课程所使用的牙科档案开展合规性分析，以验证其是否符合该国现行立法确立的伦理准则。我们向巴西牙科联邦委员会（Federal Council of Dentistry）官网注册的全部220个本科课程负责人发出邀请，最终96位（占比43.6%）同意参与本研究。数据收集与分析环节采用了涵盖伦理与立法相关问题的结构化问卷。在全部受访样本中，53.2%的课程具备全部必要的最低限度文件，但无一课程同时满足患者身份识别、病史采集记录、知情同意书以及牙科牙位图（odontogram）的全部要求。此外，仅17.8%的课程完成了诊疗计划相关的全部条目，61.5%的课程获得了数据与图像使用授权。本研究结论显示：此类牙科档案不符合现行立法要求，必须予以更新以提升信息质量，规避行政、伦理及法律层面的各类问题。