CHAP. 10 - (Personal) documentation for DH (Exam 2)

Patient Record

written document that contains information —> identify patient (care, codes, etc.)

Forensic

pertaining to or used in legal proceeding

Encryption

translation of computerized data —> secret code; most effective way to achieve data security

Symptoms

any change in body or its function that’s perceived by patients

Charting

process of tabulating clinical information on a graphic form

Chart

form/graphic representation used as a component of patient’s health record

Odontogram

graphic representation of patient hard & soft tissues

When documenting, what does it advoid & provides?

It avoid abbreviations. It provides accurate/comprehensive, legible, & objective paper.

Patient Record?

It records promptly following treatment recorded using clear, concise, objective statements dated, & signed by clinician.

*treatment notes must be completed within 24hrs

EHR (s) stand for?

Electronic Health Records ( 2014 )

What does HIPPA stand for?

Health Insurance Portability & Accountability Act.

• it applies to facilities, companies, providers

• it was effective in 2003

What are the two components of HIPPA?

1. privacy & patient’s ability to access their info

2. security of patient info in settings

What are HIPPA’s three safeguards?

1. administration (limit members)

2. physical (storage system)

3. technical (technology access)

-updated in 2013

Universal System is what?

-Started in 1880 but ADA adopted the system in 1968

-Starts with the patient’s right maxillary third molar (#1 through #32) = permanent teeth

-Uppercase letters (A-T) = primary

Federation Dentair International Two Digit (aka International)

-Permanent: divides the mouth into 4 quadrants (numbered 1 to 4).

-Teeth are numbered 1 to 8, starting from the front middle to the back.

-A tooth is named by its quadrant with the first number. Then the second number is the position

(EX: "11" is the top-right front tooth)

-Digits are pronounced separately

Palmer Notation System

-Started in 1861

-The mouth is split into four sections (upper right, upper left, lower right, and lower left) from the patient's perspective.

-Numbered 1 through 8 in each quadrant, starting from the center front tooth (central incisor is 1) out to the wisdom tooth (third molar is 8).

What does charting need?

It needs care planning, treatment, evaluation, protection, & identification

what are the two forms of charting?

1.anatomical drawings

2.geometric

two parts of stains?

1. Extrinsic - stain, color, distribution, & location

2. Intrinsic - record separately & identify by type when known

what does SOAP stand for?

subjective

objective

assessment

procedures

subjective is?

patient report (age, gender, sex, medical/social history, treatment planned)

objective is?

observations of clinician/results of clinical examinations (vital signs, head & neck exam, all the findings of & examinations of, etc.)

assessment is?

analysis or diagnosis (risk factors for oral disease, oral disease risk level, dental biofilm, calculus level, current periodontal diagnosis)

Procedures is?

plans/care or treatment provided (consults, instructions, planned, goals, medicaments)