Ch. 26 The Patient's Dental Record Overview

What specific information must the dental team receive from the patient before it can provide dental treatment?

medical history, financial status, and treatment plan.

patient registration, medical history, and informed consent.

financial status, radiographs, and treatment plan.

treatment plan, progress notes, and informed consent.

patient registration, medical history, and informed consent

Which term describes the collection of data to help the dentist make a correct diagnosis?

recall

assessment

decision

prescription

assessment

The patient record is a permanent document of whom?

the dental practice

a court of law

the patient

the dentist

the dentist

Quality assurance is an important asset of a practice because _______.

it describes how qualifies the dental staff is

it describes the financial stability of the dental practice

iit describes the location of a dental practice for a specific patient population

it describes the type of care a patient is receiving

it describes the type of care a patient is receiving

The patient should be instructed to enter his or her name on the registration form as ______.

first name and last initial only

first initial of the first, middle, and last names

first initial and last name only

first name, last name, and middle initial

first name, last name, and middle initial

A medical-dental history form is not complete until the ______ is entered.

social security number

insurance number

signature and date

chart number

signature and date

The dental history section of a health history form provides the dental team with information concerning ______.

necessary dental treatment and care needed

dental procedures that are legal for the dental assistant to complete

the address of the patient's previous dentist

previous dental treatment and type of care received

previous dental treatment and type of care received

Which medical condition would require an alert notification?

migraines

a toothache

a broken leg

an allergy to penicillin

an allergy to penicillin

What dental form would a patient review and sign if referred to a dental specialist for an extensive procedure?

treatment plan form

clinical examination form

progress notes

informed consent form

informed consent form

Before treatment, a patient's overall health and dental status is recorded on a:

medical alert information

consent form

patient registration

medical-dental health history

medical-dental health history

At the completion of the diagnostic gathering process, the dentist will:

formulate an assessment from the findings of the patient's oral health status.

present a diagnosis to the patient.

develop and document a treatment plan with input from the patient.

review all significant findings.

formulate an assessment from the findings of the patient's oral health status.

The patient record is:

a permanent document.

not considered a legal document.

a temporary document.

not sufficient enough to be used as a reference tool in a forensic case

a permanent document.

The primary source of information used to determine the overall quality of care the patient receives is the:

patient record.

patient survey.

encounter form.

treatment plan.

patient record.

A written privacy policy informing a patient that an office will not use or disclose Protected Health Information (PHI) for any purpose other than treatment, diagnosis, and billing is mandated by the:

Health Insurance Portability and Accountability Act (HIPAA).

Occupational Safety and Health Administration (OSHA).

National Institutes of Health (NIH).

American Dental Association (ADA).

Health Insurance Portability and Accountability Act (HIPAA).

A patient who reports for an initial appointment should be:

notified that the form does not need to be signed.

asked to provide a social security number.

asked to complete a medical and dental history, and be told why the information is needed.

asked to fill out patient forms and answer questions over the phone.

asked to complete a medical and dental history, and be told why the information is needed.

A patient's employment information is located on the:

patient registration form.

treatment plan.

medical-dental health history.

clinical examination form.

patient registration form.

The medical history section includes questions regarding the patient's past medical history, present physical condition,:

chronic conditions, allergies, and current medications being taken.

and chronic conditions.

chronic conditions, and allergies.

and insurance benefits.

chronic conditions, allergies, and current medications being taken.

HIPAA requires that all dental practices have a patient privacy policy that:

is in written or in oral form.

the patient must acknowledge in writing that they have received.

must be provided to the patient upon request.

allows the dental office to disclose protected health information (PHI) for any purpose they see fit.

the patient must acknowledge in writing that they have received.

To ensure patient safety, medical alerts and other precautions should be noted by:

affixing an alert sticker to the inside cover of the patient record if you are using paper forms.

posting a warning sign on the entrance to the treatment area.

affixing an alert sticker to the outside cover of the patient record if you are using paper forms.

writing the medical condition that prompted the alert on the patient bib.

affixing an alert sticker to the inside cover of the patient record if you are using paper forms.

A patient's medical-dental history should be updated:

once a year.

only after a major illness.

every 6 months.

every time the patient comes into the office.

every time the patient comes into the office.

The most graphic and detailed part of the patient record is the:

clinical examination form.

progress notes section.

patient registration form.

treatment plan.

clinical examination form.

The clinical examination form includes:

progress notes.

the plan of care.

informed consent.

charting for existing restorations and present conditions.

charting for existing restorations and present conditions.

Progress notes should document the:

different treatment alternatives.

use of insurance benefits for the current calendar or contract year.

date, tooth number, and treatment.

payment method.

date, tooth number, and treatment.

Expected outcomes of treatment and description of possible complications are recorded on the:

informed consent form.

progress notes.

clinical examination

treatment plan.

informed consent form.

Which is a diagnostic information-gathering form?

Patient registration form.

Clinical examination form.

Medical-dental health history form.

Medical alert information form.

Clinical examination form.

Guidelines for charting entries in clinical records include:

using a group chart for the entire family.

making the chart entry during the examination or patient visit.

recording the entry in pencil for easy correction.

including business and financial information as part of the clinical record.

making the chart entry during the examination or patient visit.

Which of the following is not true regarding the patient record?

The patient record can be used as a reference for appropriate third parties.

The patient record can be used for the postmortem identification.

The patient record can be used as evidence in a legal settlement.

The patient record is the property of the patient.

The patient record is the property of the patient.