Medical documentation for dental practice: requirements and legal risks
The law firm “Pravova Dopomoha” recently published an article about mandatory medical documents for dental clinics in Ukraine and the legal risks associated with their incomplete maintenance. pravdop.com. The material discusses in detail: a contract for the provision of medical services, informed consent, a medical record, a refusal letter, and recommendations after procedures. Violation of the rules for drawing up documentation can lead to fines, loss of license, or lawsuits from patients.
Why is this important?
Dentists must accurately know and apply all legal documentation requirements to protect themselves legally and ensure continuous professional activity.
The most common errors in documentation
According to inspections by the State Service for Food Safety and Consumer Protection and the National Health Service, the most common violations in dental practice are: lack of signed informed consent, unformed medical record of the established sample (form No. 043/o), lack of sterilization log or instrument processing protocols. In the event of a patient complaint, these documents can become key evidence — either in your favor or against you. Therefore, proper registration is not a formality, but a doctor’s legal shield.
Documents that have legal force in court
Judicial practice in Ukraine clearly demonstrates: when considering cases of alleged improper provision of dental care, the main evidence for the court is medical documents. If the documents do not contain the patient’s signature on familiarization with the risks or consent to a specific manipulation, the responsibility often falls on the clinic. The same applies to situations when the dentist does not record all the actions performed in the card. Thus, competent documentation can protect against significant financial and reputational losses.
How to streamline document flow in a clinic
It is recommended to introduce an internal document flow standard within the clinic. These can be contract templates, checklists for preparing the patient for procedures, a logbook for controlling the filling out of cards. It is also worth introducing a regular legal audit of documentation – once every six months – with the participation of a medical lawyer. All new employees should be instructed in filling out documents and familiarized with internal regulations. This approach creates a reliable legal basis for the dentist’s daily work.
