Your dentist has an obligation to keep a record in your name. This is an important document for your dental team to track your condition and the care you receive. Your dentist and his team are responsible for collecting all the information about you in order to keep track of all the services rendered and the results obtained following each treatment.
What are the elements that the dental record must contain, and, above all, to whom does it legally belong? To clear up the confusion, our team thought it was appropriate to prepare a blog post about it!
The usefulness of the dental record
The dental record allows the dentist to gather all the relevant information about a patient, including his or her health problems. It also details all the services that have been rendered. The file therefore plays a vital role, since the dentist refers to it to adapt his treatments, regarding the specific condition of the patient and the care he has received in the past. The dental record is therefore the MEMORY OF FACTS AND GESTURES.
At the legal level, the dental record can become an important tool for assessing the quality of the dental procedure and for demonstrating that the dentist has fulfilled his obligations to the patient. It is a document that is framed by the law and it must meet the requirements that the latter cautions. When inspecting its members, the Ordre des dentistes du Québec can check to ensure that a dental clinic keeps proper records of its patients.
What elements should be found there?
The dental record of a patient is a complete document, which contains a lot of important information. Here is a list, not exhaustive, to allow you to understand the kind of information we find:
- The dates of the consultations;
- The medical and dental history of the patient;
- The diagnoses that have been rendered by the dentist;
- Possible treatments and related prognosis (prediction of results following treatment);
- Description of all treatments and interventions that have been performed;
- The materials and drugs that are used during treatment;
- prescriptions issued by the dentist;
- The results of examinations, X-rays, etc.;
- information related to anesthesia;
- Information, advice and recommendations given to the patient by the dentist;
- Information related to professional fees.
The dental file: a confidential document
The laws governing the maintenance of dental records ensure the confidentiality of these. Dentists and their team are required to take the necessary steps to maintain the confidentiality of the information collected, whether the records are in paper or digital format.
Also, if a dentist ceases to practice, whether permanently or temporarily, the Ordre des dentistes du Québec ensures that the data presented in the patients' files of this professional are retained. She passes them on to new dentists, while continuing to ensure that the information remains confidential.
Who does the dental record belong to?
Under the law, the physical record remains the property of the dentist. However, the information therein belongs to the patient. The latter may request to consult his file or to have information corrected therein, to take a decision in his regard or to transmit the information to a third party.
If a patient wishes to change dental clinic and dentist, he may request a reproduction of his file, but to do this, his current dentist is entitled to request that reasonable expenses be disbursed.
If you have any questions about your dental record, the Dents Mon Quartier team is committed to give you as much information as you want! Do not hesitate to talk about it with us on your next visit!
Approved by Dre Charouk
Dr. Joumana Charouk, D.M.D, is proud to offer her patients exceptional care that combines experience, efficiency and good humor.
Dre Joumana Charouk, D.M.D