Dental documentation from the perspective of Legal Dentistry: integrative review

Abstract

Objective: This is an integrative review whose objective was to summarize the current literature regarding dental documentation and its applications, related to the civil liability of the dental surgeon. Methodology: A search was carried out in the databases PubMed, LILACS, Scielo and Periódicos CAPES, and in gray literature (Google Scholar) between August and September 2022, as well as in official electronic addresses to search for laws and regulations, using the combination of descriptors: “documentation”, “legal responsibility”, “dentistry” and “legal dentistry”. Results: Ten publications were found in the field of forensic dentistry, four related to dental documentation (medical records, informed consent form, odontogram, images), four related to legal actions, one on medication prescription and one on case notification suspected and confirmed cases of violence. Conclusion: Universities, higher education institutions and health units have an important role in training and qualifying dentists to correctly fill out medication prescriptions, medical records, compulsory notifications, and storage of dental documents, as well as, clarification on the dentist's subjective and objective liability, damage and causal link.