Manual de diligenciamiento de la historia clínica del paciente adulto
This teaching-support book aims to facilitate the process of preparing the clinical record of the adult patient in dental schools for teachers, undergraduate students, graduate students and dentists at the national level and in Latin American countries. In addition, to be used in institutions that provide oral health services and in scientific research.
The proper completion of the medical record of the adult patient is important for the dentist because collection of the current clinical information of the patient is crucial for an excellent professional practice. It is also a legal document that supports the decisions made by the dentist in their daily clinical practice. The clearer its completion, including the annexes, the greater the possibility of obtaining good results. This handbook consists of a guide for the recording of signs and symptoms from the patient, which are recorded through the analysis of family and personal history, including the anamnesis, intra and extraoral examination, interpretation of diagnostic aids such as radiographs, analysis of static and dynamic models and dental and periodontal evaluation in order to reach diagnoses and determine a comprehensive treatment plan for the adult patient.
