The Patient's Dental Record

Flashcards based on lecture notes about patient dental records.

What is the dental record?

A complete longitudinal history of an individual's dental care.

When communicating with a patient by phone or in person, what must be available?

The patient record must be available for reference.

What is the specific order in which a patient's record is organized?

Personal information, diagnostic findings, and documentation of treatment.

What kind of record is the dental record?

Personal and legal documentation of the patient.

What is required regarding privacy in dental practices?

HIPAA requires that all dental practices today have a written privacy policy.

What role does the dental record play in quality assurance?

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

How does the dental record aid in risk management?

Proper documentation helps avoid litigation.

What are some characteristics of paper dental records?

Inexpensive initially, easy to customize.

What is the current trend in dental record systems?

More than 75% of practices now use some form of electronic record.

What is a key benefit of electronic dental records?

Access to dental record is safeguarded.

What is a practical application of electronic dental records?

To perform practice management.

How do electronic dental records assist the dental team?

To allow the dental team to enter relevant clinical documentation, prescriptions, etc.

How do electronic dental records facilitate information sharing?

To share health information with authorized providers.

What are the components of the dental record?

Patient registration form, medical-dental health history form, medical alert information, consent forms.

What patient information is included on the patient registration form?

Full name, date of birth, residence, phone number, employment, spouse’s information.

What insurance information is included on the patient registration form?

Employee’s name and date of birth; employer’s name, address, and phone number; name of insurance carrier and policy number.

Who is the responsible party?

Person responsible for payment of the account.

Why is a signature and date needed on the patient registration form?

Used to verify the accuracy of information.

What information is included in the medical history section?

Questions regarding the patient’s medical history, present physical condition, chronic conditions, allergies, and medications currently being taken.

What information is included in the dental history section?

Information about the patient’s previous dental treatment and care and how the patient feels about dentistry and how important dental care is to him or her.

What does the medical alert section highlight?

Indications of health conditions, allergic reactions, and medications that could interfere with or be life-threatening to patient during dental treatment.

Where should medical alerts and other precautions to be placed?

Entered into dental record.

If using paper forms, what should be done to indicate a medical alert?

An “alert” sticker should be placed inside the record.

How often should a patient update their medical-dental health history?

The patient must update his or her medical-dental health history at every appointment.

What health information may have changed that requires updating?

Diagnosis of medical conditions, medications.

What are the diagnostic information-gathering forms?

Physical examination form, radiographic examination form, clinical examination form.

What is the purpose of the clinical examination form?

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

What should be included on the clinical exam sheet?

Patient’s name and date of examination.

What kind of charting should appear in the clincal examination datasheet?

Charting of existing restorations and present conditions

What kind of periodontal information should be on the sheet?

Charting of periodontal conditions.

What type of patient history should be included?

Patient’s chief complaint.

What kind of findings are included in the clinical examination sheet?

Findings of occlusal evaluations.

What is another type of finding in the clinical examination form?

Findings of temporomandibular joint evaluations.

What kind of general information is also included?

Comments

How is a treatment plan recorded?

Record the plan of care on treatment plan form.

How should the plan of care be sequenced?

Properly sequence to address all problems that were identified during examination and diagnosis portions of patient visit.

Under what circumstances can treatment plans change?

Treatment plan may change course if financial arrangements become a factor.

What is the purpose of the informed consent form?

This form, related to a specific treatment or procedure, provides the patient with the expected outcomes of treatment and describes any possible complications that might occur.

When is an informed consent form typically used?

Commonly used for invasive or extensive treatment, such as in specialty procedures.

What information is recorded in the progress notes?

Treatment is recorded in this section of the patient record.

What should always be included in the progress notes?

Date, tooth number, completed treatment, communication with patient.

How should entries be made in a patient chart?

Every entry in a chart should be made as if the chart will be seen in a court of law.

What happens after a procedure concerning the patient record?

At the conclusion of a procedure, the details of what was accomplished will be entered in the “Progress Notes” section.

How should corrections be handled in the patient record?

Incorrect information MUST be preserved and not deleted. Follow specific guidelines for paper and electronic records.

What is one of the learning objective of lesson 26.1?

To pronounce, define, and spell the key terms.

What is another learning objective of 26.1?

Explain the patient dental record and how the dentist uses the record to manage patient treatment.

What is another concept the lesson covers?

Contrast between the paper dental record and the electronic dental record systems.

Another learning objective of lesson 26.1?

Describe the components of a patient dental record.

What is another learning objective of lesson 26.1?

Describe the process of entering data in a dental record.

What textbook is being used in the transcript?

Robinson: Modern Dental Assisting 14th Edition