Patient Records/Histories

Personal History

Patient's Full Name, Address,Phone #(s), Email, Dentist and Doctor's contact information, DOB, PHC#, Dental Benefit Coverage

Medical History

Date of last medical visit, Medications, Medical conditions. assure the patient that the information requested on the Medical History is pertinent to their care and that there is a good reason for each question. 

Be familiar with the questions and the reasons for each. This will enable the assistant to answer any questions and be alerted to matters that will affect patient care during treatment.

Dental History

Date of last dental exam, Information about previous dental treatment, Patient dental IQ and concerns

What can be found in Dental records as aresult of dental treatment

• dental practice forms

• examination information

• diagnostic records

Patient Charts

Provides information that allows

effective communication between the

Dental Team and the Patient.

 Should be:

• Detailed

• Chronological

• Accurate

• Legible

• Confidential

Main purpose of detailed medical history

Provides an overall view of the patient to assist in diagnosis and treatments planning

Key actions when reviewing medical history with a patient

Review it together and ask follow up questions to ensure all information

Requirement for patient records in court

They must be date and signed to be used as a legal evidence

Owner of patient dental records

Dental practice

Patient rights regarding dental records

Legal right to request and receive a copy of their records

Record retention period for adult patients

10 years after the last treatment date

Record retention period for minor patients

10 years after reaching the age of majority (18)

What do Records include?

• patients records (charts)

• X-rays (radiograph)

• models (Stone/plaster casts)

• Any other record that

  documents patient

  involvement in the practice

  
  

Medical History

Any condition that may affect oral tissues or dental treatment MUST be brought to the attention of the dental team.

Rules for record keeping?

• Permanent INK

If errors occur: do not erase or alter. All errors must be crossed out and initialed. Then the correct information is written legibly in its

place.

• Detailed and chronological. All information is written in the order in which the services were delivered

• Accurate

• Legible

• Consistent