Week 2 - Patient Records/Charts

Why are patient records important? When to record?

Accurate dental records protect both the patient’s and the oral health care provider

• It is very important to gather necessary information from a patient before the beginning any dental care

Which document is considered the principal document? used when?

The patient record is the principal document containing critical information you will need to manage each patient in the dental practice

• Whether you are communicating with a patient by phone or in person, the patient record must be available for reference

What’s special about the order of patient record?

A patient’s record is organized in a specific order to allow the dental team to move from the patient’s personal information, to the diagnostic findings, and then finally the documentation of treatment

what’s the importance of a dental clinic record? (5)

1. guides/directs dental care

2. insurance audits/financial implications

3. legal document

4. taxes

5. assists in forensic evidence

How does dental clinical record act as a guide for dental care team? (4)

1. Basis for diagnosis and treatment plan

2. Assists oral health professionals in their day-to-day practice.

3. Accurate chronological records help practitioners provide comprehensive care and ensure continuity and consistency between practitioners

4. Includes response to treatment

how is dental clinical record a legal document?

Legal document to accurately and adequately depict a client’s general and oral health, concerns, and services provided

• Evidence in a court of law

What common forms are used for patient records? (7)

1. patient registration form

2. medical/dental history form (vital signs)

3. consent form

4. diagnostic information forms (including clinical examination)

5. treatment plan

6. informed consent (w/ minors)

7. progress notes (treatment notes)

Which forms are completed by the patient? (3)

1. patient registration form

2. medical/dental history form

3. consent form (for treatment - also privacy & financial policies)

• shows patient read form so protects you legally. also cover verbally

Which forms are completed by the dental staff? (4)

1. diagnostic forms

2. informed consent

3. treatment plans

4. progress notes

What does the patient registration form include? (3) What is mandatory? (1)

• Patient information including full name, date of birth, address, telephone numbers (home, cell, work), employment information, spousal information, and emergency contact

• Insurance information

• Responsible party indicates who will pay for treatment

Patient signature and date is really important

Why does a medical/dental history form need to be completed by patient?

provides an overview of the patient’s past medical and dental health conditions.

What is included in a diagnostic form? (3)

1. Physical Examination form which most often is used to record the patient’s vital signs

2. Radiographic Examination

3. Clinical Examination form which records the results of the intra- and extra-oral examination.

Why is an informed consent form important?

for specific treatment to be undertaken, such as consent to remove an infected tooth

What are treatment plans? progress notes?

Treatment Plans

• records the details of any planned treatment (Robinson and Sell 2026)

Progress Notes

• a record of actual treatment provided to the patient

What is a dental record viewed as? (2)

1. is a means of communication

2. is a legal document

What are general rules about the dental record? (4)

1. Documentation should occur during or immediately after patient visits

2. Documentation should be made in chronological order (order of treatment)

3. The use of unique abbreviations that can not be easily understood by others should not be used

4. Never include speculation or derogatory statements in a dental record

How to maintain the dental record as a legal document? (10)

1. Each component of the patient’s record needs to be marked with patient’s name (first and last)

2. Health histories and vital signs need to be updated regularly and should be documented comprehensively

3. use permanent Pen: Do not change colours of pen halfway through entry (blue or black only)

4. Write neatly and clearly

   1. For mistakes stroke out with one clean line, initial

   2. Scribbling incorrect information and/or erasing/using “white out” defended in a court of law

5. Ensure information is relevant and accurate

6. Use uniform terminology and abbreviations

7. record immediately and in order of treatment

8. Ensure warning/caution indicators stand out

   1. Pre-medications

   2. Allergies

   3. Phobias/Anxiety

9. Whomever provided the service records in the chart

10. All records must be dated, signed and/or initialed by the person who is recording the record

How to maintain infection prevention and control (IPC) with dental records?

Paper records

• This may include using plastic barriers to cover papers and pens

Electronic records

• plastic barriers for computer keyboards and mouse, as well as disinfection of chairside monitors

Why are systematic (consistent and specific) chart entries helpful? (3)

1. Assures that no details are missing from the patient’s record

2. Aids in ensuring records are sufficiently detailed (read easily by other professionals)

3. Acronyms can provide guidance and uniformity in record keeping

What are three ways to have systematic chart entries? What does sait use?

SOAP

• S- subjective

• O-objective

• A-assessment

• P-plan

RATPP

• R-reason

• A-anesthetic used

• T-treatment

• P-post-operative

• P-plan for next visit

PARTS (used at sait)

• problem or procedure

• A-assessment

• R-requisitioned/recommendations

• T-treatment

• S-summary/subsequent advice

  • something always included, either more treatment or regular check up

• also comments section for how appointment went, if some changes happened or N/A

PARTS explained?

P = Procedure: what procedure/treatment are you planning on doing today? Identify any problems the patient may be concerned about.

A = Assessment: medical history update and notes about the patient’s health, including oral health and vital signs and clinical Observations

R = Requisitions/recommendations if not applicable

T= Treatment: document the procedures that were completed at the appointment

S= Strategy/Summary : What is the plan following this appointment

Comments: This is where you put any information that does not fit into any of the above, but that you feel it is important to make note of