Patient record in facial harmonization: what it is and contains

The patient record is the set of documents that records everything done with a patient: assessment, decisions, procedures, complications and progress. As to its content, it belongs to the patient, and it is kept by the professional or the clinic. In orofacial harmonization, it is the technical memory and the main documentary proof of the care provided.

What does the patient record usually contain?

• Patient identification.
• Medical history and its updates.
• Clinical exam and facial assessment.
• Proposed treatment plan and what was accepted.
• Informed consent and authorization to use images.
• Record of each procedure: date, area, product, lot, expiration and volume.
• Standardized photographs of before, after and follow-ups.
• Complications, actions taken and guidance given to the patient.

Why is it so important?

The patient record ensures continuity of care: at a follow-up or in a complication, it is what says what was applied, where and how much. It is also mandatory under the rules of Brazilian professional councils and serves as documentation in case of an ethical or legal challenge. An incomplete record usually weighs against the professional.

Because it gathers health data and images, the patient record needs restricted access and secure storage, following the LGPD (Brazil's General Data Protection Law). The format (paper or electronic), the retention period and the signature requirements vary according to the rules of each professional council.

In Harmy

Harmy's history keeps the sessions by patient with the photo, the projection and the actual result, which helps organize the images. It does not replace the clinical record, which must contain the other entries.

Also called: clinical record, dental record, clinical chart.