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Abstract

The objective of this present study was to evaluate the completion of medical records by undergraduate students at the Integrated Children's of a South Brazilian Graduation Institution over the past five years, as well as the quality of the radiographs obtained by them. After the University Research Ethics Committee approval, the data were collected by previously calibrated undergraduate students, at Children’s Clinic through patients records up to 12 years, totaling a sample of 378 medical records and 354 radiographs. The collected data include patient identification, documentation, clinical data, procedures and other information that make up the dental record, as well as radiographic errors involving processing, technique and radiographs storage. It was possible to verify that 50% of the records filled out by the students have the completion of the dental chart, but there was no signature of the legal responsible; that approximately 53% did not have a planning or even an odontogram completed; There was no significance regarding to age and odontogram complexion. Among the radiographs evaluated, 66% were children over 7 years old, 50% male, 68.5% performed by the periapical technique. From the observed the “incorrect storage” was the most present, followed by the “presence of digital” error. Errors during radiographic taking ranged from 1.1 to 22%. It was concluded that the quality of the medical records filling made by the undergraduate students is unsatisfactory, as well as the quality of the radiographs and their storage.