Analysis of the Filing Compliance of Dental Records at a Private University Center in Belo Horizonte, Minas Gerais.

Abstract

The dental record is an essential document in the field of oral health, containing detailed information about each patient's history and treatment. Its proper maintenance is crucial for ensuring effective care, besides possessing clinical, administrative, and legal relevance. Standardized by the Code of Dental Ethics, its preparation and updating are mandatory; however, studies indicate deficiencies in its compliance and completion, including in academic settings. This study aimed to evaluate the compliance and quality of completion of dental records at a University Center in Belo Horizonte, through a literature review and data collection. A total of 622 clinical records were analyzed; of these, 107 were excluded for not meeting the eligibility criteria. The study was then conducted by observing the completion of 515 records. There was a large variation in the extent of completion for each record, with most fields being partially completed. Only 1 record had all its sections fully completed. It is concluded that there are gaps in the documentation completion, underscoring the need to reinforce the importance of documentation during clinical practices and in student training.