Dental records module 3 test

patient record and charting

Dental record

Full complete history of an individuals dental care, it is a permanent record that contains personal and legal documentation of the patient

Types of dental records

Paper and Electronic

Components of the dental record

Information gathering forms. (patient registration form, medical-dental health history form, medical alert information, consent forms.)

Medical Alert

Tagged note of Health conditions, allergic reactions, medications, that could interfere with patient during dental treatment

Medical-Dental health history

Must be updated at every appointment, information such as diagnosis of medical conditions/new medications.

Forms needed for diagnostic information

Physical examination form, radiographic examination form, clinical examination form

clinical examination form

Provides the dental team with past, present, and future examination, analysis, and charting needs of the patient

Treatment plan

record the plan of care on the treatment plan form, sequenced to address all problems that were found during examination and diagnosis portions of patient visits.

Factor that may change the treatment plan

Financial arrangements

informed consent form

Related to a specific treatment or procedure, gives patient with expected outcomes of treatment and describes any possible complications that may occur. *commonly used for invasive or extensive treatment*

progress notes

where treatment is recorded, ALWAYS INCLUDES: date, tooth number, completed treatment and communication with patient

HIPAA

Requires that all dental practices today have a written privacy policy (United States)

PIPEDA

Personal information protection act (Canada)

PHIA

Personal health information act (Nova Scotia)

Quality assurance

The primary source of information used by the dental team to determine the overall quality of care the patient has received.

Risk management

proper documentation helps avoid litigation

Anatomical chart

Shows full detailed dentition (includes previous work and work that needs to be done)

Geometric chart

Shows full, less detailed dentition in small circles (includes previous work and work that needs to be done)

S

tooth has a sealant

O

Restoration (filling) on the occlusal

MOD

restoration (filling) on the mesial occlusal distal

O

Restoration required on the occlusal

O

Recurrent decay

Class IV restoration

X

tooth is missing

X

tooth needs to be extracted

Tooth is impacted or not erupted

tooth is rotated, *curve arrow in direction of rotation!* (mesial or distal)

tooth has drifted, *straight arrow in direction of drifting* (mesial or distal)

Tooth is missing and the space is closed *arrows must touch*

tooth is fractured *jagged line drawn where fracture is*

Tooth has a veneer, *C or P above tooth to indicate material*

Cr

Full crown *would also write material used (PFM, gold, etc)*

RCT

Root canal therapy

Tooth has a RCT, post/core/crown

Br

Fixed bridge

Diastema

Two restorations separated on the same tooth

Complete or partial denture (removable)

Blacks classifications of cavities

Classifies the location and description of the carious lesion using Roman Numerals

Class I

Decay in pits and fissures of molars and premolars and/or in lingual pit of max incisor

Class II

Decay on Proximal mesial or distal surfaces of PREMOLARS and MOLARS

Class III

Decay is on proximal mesial or distal surfaces of anterior teeth

Class IV

Chipped tooth restoration, anterior teeth

Class V

Decay towards gingiva of ANY tooth *think V shape*

Class VI

Decay on incisal edges of anterior teeth, often from grinding *newest class*

How long must we keep the patient record?

10 years

Who signs the dental assistants entries in patient record?

Dentist

Restoration

replaces tooth structure, often known as FILLINGS

Periodontal pocket

space in the gingival sulcus increased by periodontal disease, healthy depth is 1-3mm

Mobility

when tooth moves in socket from periodontal disease/trauma

overhang

excessive restorative material found interproximally near the gingiva

crown

permanent or temporary (provisional) *gold, porcelain, porcelain fused to metal, stainless steel or acrylic*

denture

full dentures if all teeth in one arch are missing, partial if only some teeth are missing

abscess

localized area of infection

bridge (fixed)

prosthetic device placed between teeth covering space (replacing a tooth or teeth)

drifting

when a tooth is removed, opposing teeth may move/erupt in space

incipient

beginning decay that has not broken through the enamel

root canal therapy (RCT)

removal of pulp and replacement with filling material

sealant

resin material used to seal pits and to prevent potential decay

mixed dentition charting

documentation must include what is missing from primary (fell out) and what is existing or erupted (came in) from the permanent dentition

Clinical comments section

Write specific comments on information obtained

Clinical notes

Space where we record the documentation of services, treatment provided including “fee code” and everything specifically done during a procedure

If someone has braces, where does it get written in the dental record?

Note section