Avaliação da ausência de documentos obrigatórios dos prontuários da clínica integrada da faculdade Unisociesc de Jaraguá do Sul
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Data
2023-12
Tipo de documento
Artigo Científico
Título da Revista
ISSN da Revista
Título de Volume
Área do conhecimento
Modalidade de acesso
Acesso fechado
Editora
Autores
JAREMCZUK, Thalita Fernanda Alves
Orientador
FERNANDES, Leonardo Alexandre
Coorientador
OHIRA, Eduardo Terumi Blatt
Resumo
Resumo: O prontuário odontológico é um documento muito importante que envolve aspectos éticos e legais. Ele deve ser bem formulado, sem rasuras e contendo o máximo de informações e dados verdadeiros sobre o paciente. Tanto em consultórios particulares como em clínicas de faculdade, os pacientes, professores e alunos possuem judicialmente os mesmos direitos e obrigações como qualquer outro e devem seguir todas as regras atribuídas conforme o Regimento Federal de Odontologia exige. Objetivo: O objetivo do presente trabalho é avaliar ausência de documentos obrigatórios nos prontuários da Clínica Integrada de Odontologia da Faculdade Unisociesc de Jaraguá do Sul. Métodos: Realizou-se um estudo transversal e descritivo para analisar e avaliar os prontuários inadequados da clínica, agrupados em ficha padrão considerando os requisitos mínimos e legais recomendados pelo CFO, que são eles: a) dados iniciais; b) anamnese; c) plano de tratamento; d) termo de compromisso livre e esclarecido e) ficha clínica de descrição de procedimentos. Resultados: O plano de tratamento foi o documento menos encontrado durante a pesquisa, não estando anexado em 64% dos prontuários; a ficha de anamnese estava presente em 96%; o termo de compromisso livre e esclarecido (TCLE) estava ausente em 8%; com relação a ficha de procedimentos realizados 95% possuíam esse documento e o formulário dos dados do paciente não estava presente e preenchido em 2%. Conclusão: A pesquisa revelou que a maioria dos prontuários possuía pelo menos um documento faltando, especialmente no que se diz respeito ao plano de tratamento. Embora os resultados apresentem índices menores que a literatura, é crucial manter a atenção dos professores e alunos para assegurar a conformidade legal na elaboração e manutenção dos prontuários odontológicos.
Abstract: The dental record is a highly important document that involves ethical and legal aspects. It must be well-formulated, without erasures, containing maximum accurate information about the patient. In both private practices and university clinics, patients, professors, and students have the same legal rights and obligations as anyone else, following all rules outlined by the Federal Dentistry Council. Objective: This study aims to assess the absence of mandatory documents in the records of the Integrated Dentistry Clinic at Unisociesc College in Jaraguá do Sul. Methods: A cross-sectional and descriptive study was conducted to analyze and evaluate inadequate clinic records, grouped in a standard form considering the minimum legal requirements recommended by the CFO, including: a) initial data; b) medical history; c) treatment plan; d) informed consent form; and e) clinical procedure description form. Results: The treatment plan was the least found document, missing in 64% of records; the medical history form was present in 96%; the Informed Consent Form (ICF) was absent in 8%; regarding the procedure description form, 95% had this document, and the patient data form was not present and filled out in 2%. Conclusion: The research revealed that the majority of records had at least one missing document, especially concerning the treatment plan. Although the results show lower rates than the literature, it is crucial to maintain the attention of professors and students to ensure legal compliance in the creation and maintenance of dental records
Abstract: The dental record is a highly important document that involves ethical and legal aspects. It must be well-formulated, without erasures, containing maximum accurate information about the patient. In both private practices and university clinics, patients, professors, and students have the same legal rights and obligations as anyone else, following all rules outlined by the Federal Dentistry Council. Objective: This study aims to assess the absence of mandatory documents in the records of the Integrated Dentistry Clinic at Unisociesc College in Jaraguá do Sul. Methods: A cross-sectional and descriptive study was conducted to analyze and evaluate inadequate clinic records, grouped in a standard form considering the minimum legal requirements recommended by the CFO, including: a) initial data; b) medical history; c) treatment plan; d) informed consent form; and e) clinical procedure description form. Results: The treatment plan was the least found document, missing in 64% of records; the medical history form was present in 96%; the Informed Consent Form (ICF) was absent in 8%; regarding the procedure description form, 95% had this document, and the patient data form was not present and filled out in 2%. Conclusion: The research revealed that the majority of records had at least one missing document, especially concerning the treatment plan. Although the results show lower rates than the literature, it is crucial to maintain the attention of professors and students to ensure legal compliance in the creation and maintenance of dental records
Palavras-chave
prontuários, responsabilidade legal, ética odontológica, ficha clínica