Estructura de la Historia Clínica utilizada en la práctica odontológica privada en la ciudad de Mérida, Venezuela

Abstract

The dental clinical history is a document of universal, medical- legal, confidential use, prepared through the collection of data obtained from the patient through interrogation and clinical examination, interpreted by the dentist to conclude with a diagnosis, prognosis and treatment; also, record procedures performed and administrative register. It has been studied dental documents from the dicoursive perspective and also some proposals of dental charts has been made. However, in the reviewed literature, no studies were found that analyze the structure of this document. The aim of this research is to describe the structure of the dental history used in private dental practice in Merida, Venezuela. Descriptive, mixed approach. Genre analysis was used to identify frequency and sequentiality of elements; additionally, a semi-structured interview was applied to contrast the analysis with the opinion of expert informants. It was found that the dental medical history is made up of eleven successive sections: (a) institutional information; (b) document title; (c)date; (d) identification of the patient; (e) anamnesis; (f) evaluation of the patient; (g) diagnostic and treatment plan; (h)side notes;(i) record of activities carried; (j) signatures and (k) attached documents. The dental medical history is a mandatory registration document. Its format must be organized to collect information in an orderly, fluid and efficient manner. It is essential that it be backed by the signature of both the patient and the dentist.