Video Notes Flashcards: Informed Consent and Dental Records (Vocabulary)

Vocabulary flashcards covering key terms from the video notes on informed consent, documentation, HIPAA, referrals, abuse reporting, and dental record-keeping.

Informed consent

Patient's agreement to undergo proposed treatment after receiving information about the nature, benefits, risks, alternatives, and consequences of not treating.

Written informed consent

A formal document used for extensive, invasive, or risky treatment; signed by the patient and a witness; original kept in the chart with a copy provided to the patient.

Witness to consent

A third party (often a staff member) who signs to attest that the patient gave informed consent.

Original vs. copy of consent

Original consent form stays in the chart; patient receives a copy; originals may be scanned or discarded according to policy.

Scanned consent forms / electronic records

Consent documents scanned into electronic records; may reduce need to keep physical originals, depending on office policy.

Content of informed consent forms

Should include nature of the proposed treatment, benefits and options, risks, consequences of not treating, and case-specific information.

Photographs consent

Consent required to use patient identifiable photos (e.g., before/after) in social media or marketing; anonymity or explicit permission may be needed.

Minor/long-term treatment consent

Special considerations for consent when treating minors or when treatment may span more than a year; may require additional consent.

Referral to a specialist

Dentist informs the patient when services cannot be performed in-office and assists in finding an appropriate specialist; document referral.

Endodontist

Dental specialist who performs root canal therapy.

Periodontist

Dental specialist who treats gum and supporting structures and manages periodontal disease.

Oral surgeon

Dental specialist who performs surgical procedures such as extractions, implants, and complex oral surgeries.

Guarantees

Outcomes of dental care cannot be guaranteed; promising guarantees is unethical and may be illegal in some states.

Contributory negligence

Failure to meet the standard of care; must document broken or canceled appointments and other factors affecting treatment.

Ownership and access to records

Dentist owns the records and radiographs; patients have the right to review and retrieve; originals rarely leave practice; copies or duplicates may suffice.

HIPAA basics

Health Insurance Portability and Accountability Act; protects patient confidentiality and governs handling of protected health information.

HIPAA disposal and retention

Secure disposal of records; shredding where appropriate; retention typically required for several years (often seven) depending on jurisdiction.

Mandatory reporting and abuse indicators

Healthcare professionals may be mandated reporters; immunity from liability when reporting suspected abuse; look for signs of abuse (e.g., injuries around the mouth/face) and report as required.