Patient record

Patient record

The patient file is a central element of medical and dental practice. As a true record of care, it ensures coherent patient management, provides traceability of procedures, and offers legal protection for the practitioner. In implant surgery—where intervention complexity requires exceptional rigor—the patient file takes on a strategic role.

A Strict Regulatory Framework

According to Article R.1112-2 of the French Public Health Code, every healthcare professional is legally required to create and maintain a file for each patient. This file must include, at a minimum:

The patient’s identity

Medical history and disclosed health information

Results from clinical and paraclinical examinations

Surgical reports

Prescriptions issued

Correspondence from other healthcare providers involved in care

The French National Authority for Health (HAS) also emphasizes the need for complete and well-structured documentation, especially in invasive procedures like implantology.

Patient files must be stored for at least 10 years from the date of the last procedure or consultation—and longer in the case of legal disputes.

Implantology-Specific Issues

In implant surgery, patient documentation must meet strict traceability requirements, including:

The surgical protocol followed

Operating conditions (surgical field setup, asepsis, procedure duration)

Details of implants placed (reference numbers, batch numbers, brand)

Any intra- or post-operative complications

Post-operative instructions provided to the patient

Complete traceability not only enhances clinical follow-up but also meets material safety (matériovigilance)obligations.

An Essential Medico-Legal Safeguard

The patient file often serves as the only admissible evidence in the event of litigation. It must therefore accurately reflect every step of the care pathway:

Informed consent

Risk disclosures

Justification of treatment choices

Post-operative follow-up

An incomplete or vague file can weaken the practitioner’s defense in court. The file is not just administrative—it's a legal safeguard.

The Shift Toward Digital Records

Many practices now use software solutions to manage patient files digitally. These tools offer several advantages:

Centralized data management

Improved legibility

Integration of images (scans, X-rays)

Automated alerts for follow-ups or reminders

However, digital patient records must fully comply with the General Data Protection Regulation (GDPR). This includes securing access, ensuring confidentiality, and respecting patients’ rights (access, correction, deletion).

A Strategic Tool for Implant Treatment Planning

The patient file is more than a record—it is a planning tool for implant treatments. It enables practitioners to:

Track clinical progression

Adjust protocols based on findings

Prepare surgical guides using imaging data

Collaborate efficiently with the care team

Thus, it becomes a quality driver that supports evidence-based dental medicine.

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