Goals Of Clinical Documentation

Goal 3: Protecting from a Medico-Legal Angle.

The third goal for documenting clinical cases is to present it as a potential key in evidence-based dentistry. The cases of child abuse, unintentional trauma, treatments done in patient interest sometimes raises questions on the ethical background and judicial enforcements of the profession. In such cases, the clinical documentation supports the treatment given and helps in determining the court of law in judgements. A clinical documentation is always advised in child abuse cases and suspected harassment cases with alveolar trauma and fractures to present as an evidence in the judicial peripheries. In the recent world where the patient has developed both economically and intellectually, it is wiser for a practioners to harbour the practise of clinical documentation in his practise.

Goal 4: Peer Reference and Health Education.

Health education is an important aspect for every dentist. As a doctor, it is not our sole duty to treat the patient but also to teach the patient and by extension, the society. Clinical documentation gives a shape and form to our work and helps in the promotion and presentation of the same before the society. Many a times the referred word about a particular treatment becomes the centre of demands whereas the new advanced but relatively uncommon treatments do not impress the patients without any review. In such cases visual references through clinical documentations helps in promoting & convincing them. This not only urges the patient to try something new but also gives birth to new ideas in society. Pedodontists successfully use this method to win the confidence of young patients. Clinical documentation also helps in peer reference where a case can be discussed with more than one doctor without even disclosing the identity of the patient. The advantage is the opinion of any doctor on this case would be based on differential views and not on conflict of interest. Clinical documentation of peculiar cases becomes a learning hub for upcoming dentists and juvenile practitioners.

Goal 5: Public Health Epidemiological Studies.

In the subject of public health dentistry, it has been observed that the dentists and practitioners who need to have comparitive and longitudinal studies often get disappointed with attrition of their subjects but a clinical documentation always helps in analysing the data even if the subject is not around. In this way clinical documentations always help in testimonial survey statistics and support the survey, findings, observations, and in certain cases act as a fixed control. In certain studies of epidemiology there is a demand of a standard, which sometimes is provided by the clinical documentation for matching of accuracy.

Conclusion

The necessity of clinical documentation can not be subjected to debate. Clinical documentation not only help a practitioner grow in his field individually but also help in maintain a developing and securing environment as the curator of the facts. In the case of forensics, documentation supports the theoretical assumptions and gives them a shape of actual investigation rather than the basis of factual investigation. It not only acts a control to the future treatments but can be used widely in terms of mass media promotion and social learning. Step wise documentation always forms a basis of passive observational learning and helps in a smooth finish of the treatment.

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