Dental Procedures & Techniques- Ch 26

A patient chart is a?

1. Permanent record 

1A. Personal and legal documentation of the patient

• Legal evidence in a settlement or lawsuit

• Reference for appropriate third parties, such as dental insurance companies and government-aided programs

• Reference tool in a forensic case for evidence in identifying and individual with the use of radiographs or study casts.

2. Private 

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

3. Quality assurance 

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

Personal Health Information (PHI)

1. Two areas of PHI as related to patient dental record

• Personal information

• Health information

2. HIPAA enforces that physical, technical, and administrative safeguards must be implemented

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

Quality Assurance

Routine forms are completed by each patient and verified with their signature and date

Timely “recall” of patients is followed to address their dental needs

A completed patient record is kept for each “active” patient in the dental practice

Documentation of when radiographs were taken

Current and up-to-date emergency standards maintained by the dental team

Current and up-to-date licenses, registrations, and certifications and training of dental team staff

Risk Management and Research

1. Risk management

• The patient record provides documentation of the patient’s condition, diagnoses, treatment, and the patient’s responses to treatment

2. Research

• The patient record provides a source of data for research purposes

Electronic Dental Record (EDR)

1. Most dramatic change in the dental practice over the last 20 years

2. Benefits to going paperless include:

• Access to dental record is safeguarded

• To perform practice management

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

• To share health information with authorized providers

Types of Patient Record Forms

Patient registration form

Medical-dental health history form

Medical alert information

Consent forms

Patient Registration

1. Patient information

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

2. Insurance information

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

3. Responsible party

• Person responsible for payment of the account

4. Signature and date

• Used to verify the accuracy of information

Medical-Dental Health History

1. Medical history

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

2. Dental history

• 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

Medical Alert

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

Medical alerts and other precautions should be entered into dental record

If using paper forms, an “alert” sticker should be placed inside the record

Medical-Dental Health History Update

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

2. Health information that may have changed

• Diagnosis of medical conditions

• Medications

Diagnostic Information-Gathering Forms

Physical examination form

Radiographic examination

Clinical examination

Clinical Examination Form

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

• Patient’s name and date of examination

• Charting of existing restorations and present conditions

• Charting of periodontal conditions

• Patient’s chief complaint

• Findings of occlusal evaluations

• Findings of temporomandibular joint evaluations

• Comments

Treatment Plan

Record the plan of care on treatment plan form

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

Treatment plan may change course if financial arrangements become a factor

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

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

Progress Notes

Treatment is recorded in this section of the patient record

Always include:

• Date

• Tooth number

• Completed treatment

• Communication with patient

• What step is next.

Entering Data in a Patient Record

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

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

• Include information about the patient’s vital signs, scheduled treatment for the day, the procedure performed with the tooth number and surface related to the procedure

• All pertinent information must be recorded in the dental record

• Entries must be clear and concise and recorded in black ink

Remember that!!!!!!

1. It is better to chart too much information than too little.

2. Make the chart entry during the examination or patient visit.  The longer the time between the procedure and the charting entry, the greater is the chance for error.

3. Write legibly, in ink.  Date and sign the entry.

4. The chart entry should be sufficiently complete to indicate that nothing was neglected; this includes the reason for the visit, detains of the treatment provided, and a record of all instructions to the patient, prescriptions and referrals.

5. If a charting error occurs, correct it properly!

6. If you didn’t chart it, it didn’t happen!