Legislation and Interpersonal Relations in Dentistry
It is very important that the dentist understand the legislation that regulates dental practice. For this, we have developed a well summarized material with the main information you need.
Dental Documentation
"The Dental Surgeon has to be especially careful with his Dental documentation both in its Clinical, Administrative and Legal aspects."
The dental surgeon has a great responsibility, as he will take care of the health of his fellowmen. Taking this as a principle, some ethical and legal norms guide the professional in his work activity.
Therefore, it is of utmost importance that the documentation starts to have the characteristics of a medical record, which must include:
Anamnesis
The patient's previous condition cannot be proven except by the perfect record of his conditions and the detailed documentation of his evolution. The dental documentation therefore serves as “pre-constituted” evidence. Either it is done in due time, or there will be no more opportunity to do it. One of these moments is related to the collection of data on the general health of the patient.
The anamnesis must always be signed by the patient.
Clinical Record
It is an integral part of the medical record and must be able to represent not only the planning of the contracted treatment, but also to substantiate any allegations related to the complications of the treatment execution. Thus, the patient's general oral condition must be included in the clinical record before treatment is initiated in order to safeguard eventual responsibility for operational acts not performed by the professional.
Treatment Plan
The treatment plan cannot be treated as a “budget” to define the consequences of the diagnostic, therapeutic and prognostic phase, as they are sometimes unpredictable, given the dental response. Regarding the notes regarding the patient's previous condition, the clinical record must reflect not only the clinical acts performed and the materials used, but also detail the occurrences such as absences, lack of cooperation, hygiene conditions and others that, in some way, may interfere with the result expected by the patient or even by the professional.
Recipes
The prescriptions will be analyzed as pertinent to the dental record and, as such, analyzed as a odontolegal document, a copy of which must be attached to the patient's record.
Dental certificates
Like receipts, certificates are legal documents. The certificate is divided into three parts:
1- Qualifications of the professional;
2- Patient qualification (patient identification and purpose for which it is intended);
3- Declaration that the patient was under his professional care without specifying the nature of the care.
Models
The models may constitute elements of judicial evidence, so it is recommended that the custody of the most complicated cases and the copy of the other cases.
Xrays
It is one of the complementary exams most performed by dentists who are present in most cases, as evidence. For this reason, the professionals' attention is called to the need to adopt the system of duplication of them, preventively or in the event of being requested by the justice.
Orientation for postoperative or hygiene
They also represent evidence of the duty of care. They can be prepared in their own forms or not, and it is important that they are delivered by means of a signature receipt, in copy or in a protocol book.
Abandonment of treatment by the patient
In the event of absences or when the patient fails to schedule scheduled appointments for the continuity of treatment, the dental surgeon must send registered correspondence. In the absence of an answer, the correspondence must be reiterated within 15 or 30 days, so that the abandonment is characterized.
What are the just causes for breaking the dental secret?
- 1º. It is understood as just cause, mainly:
a) compulsory notification of illness;
b) collaboration with justice in cases provided for by law;
c) dental expertise within its exact limits;
d) strict defense of the legitimate interest of the registered professionals;
e) disclosure of confidential facts to the person responsible for the incapacitated person.
- Patient with sexually transmitted diseases who refuses to tell their partner about their health status, the dentist is allowed to pass on the information for a just cause *
- 2. It is not a breach of professional secrecy to declare the treatment undertaken, in the judicial collection of professional fees.
Eclectic School: may be revealed before legal, ethical, moral and social values of revelation.
154 - penalty: assessment from 3 months to 1 year → revealing without just cause;
269 - penalty: imprisonment from 6 months to 2 years, or a fine → if you fail to reveal a compulsory illness.
Art 10. Chapter VI - professional secrecy
It constitutes ethical inflation:
I - reveal, without just cause, a confidential fact that he is aware of due to the exercise of his profession.
II - neglect in the guidance of its collaborators regarding professional secrecy
Of the Rights and Duties of the Dental Surgeon
Chapter II
FUNDAMENTAL RIGHTS
Art.3º. The fundamental rights of registered professionals, according to their specific duties, are:
I - to diagnose, plan and execute treatments, with freedom of conviction, within the limits of their attributions, observing the current state of science and their professional dignity;
II - protect professional secrecy;
III - contract professional services in accordance with the provisions of this Code;
IV - refuse to practice the profession in public or private areas where working conditions are not dignified, safe and healthy;
V - right to waive patient care during treatment, when facts are found that, at the professional's discretion, impair the good relationship with the patient or full professional performance. In these cases, the professional has the duty to inform the patient or his legal guardian in advance, ensuring the continuity of treatment and providing all the necessary information to the dental surgeon who succeeds him;
VI - to refuse any statutory or regulatory provision of a public or private institution that limits the choice of means to be put into practice for the establishment of the diagnosis and for the execution of the treatment, except when for the benefit or the free choice of the patient.
Chapter III
FUNDAMENTAL DUTIES
Art. 4. In order to guarantee compliance and full execution of this Code, it is up to the dental surgeon and other registrants to communicate to the CRO, with discretion and justification, facts of which they are aware and characterize a possible violation of this Code and the Regulations the practice of Dentistry.
5th. The fundamental duties of dentistry professionals and entities are:
I - watch over and work for the perfect ethical performance of Dentistry and for the prestige and good concept of the profession;
II - ensure adequate conditions for the ethical and professional performance of Dentistry, when invested in a management or technical responsible role;
III - exercise the profession maintaining dignified behavior;
IV - keep professional, technical-scientific and cultural knowledge up to date, necessary for the full performance of professional practice;
V - to care for the patient's health and dignity;
VI - keep professional secrecy;
VII - promote collective health in the performance of their functions, positions and citizenship, regardless of exercising the profession in the public or private sector;
VIII - elaborate and keep updated the medical records of patients, keeping them in their own file;
IX - to point out flaws in the regulations and rules of the institutions in which he works, when he deems them unworthy for the exercise of the profession or harmful to the patient, and should, in these cases, go to Organs competent bodies;
X - advocate for harmony in the class;
XI - abstain from the practice of acts that imply the commodification of Dentistry or its poor conceptualization;
XII - assume responsibility for the acts performed;
XIII - always protect the patient's privacy;
XIV - not to maintain ties with entities, companies or other purposes that characterize them as employees, accredited or cooperated when they are in an illegal, irregular or unlawful situation;
XV - communicate to the Regional Councils about activities that characterize the illegal practice of Dentistry and that they are aware of;
XVI - guarantee to the patient or his legal guardian, access to his medical records, whenever expressly requested, and may grant a copy of the document, upon receipt of delivery;
XVII - register, the technical and laboratory procedures performed, keeping them in its own file, when technician in dental prosthesis.
There, now that you know how to insure yourself and protect your patient.
Source: Odonto UP. Available at: https://www.odontoup.com.br/resumo-legislacao-e-relacoes-interpessoais/. Access on: 05/26/2021.