Dental Hygiene Documentation and Charting Essentials

Vocabulary flashcards covering key concepts from dental documentation, privacy, charting, and tooth numbering systems.

Documentation in a patient’s record

Legal evidence in any legal action.

Initial and continuing exam information

Part of the permanent record; all information collected is included.

HIPAA

Health Insurance Portability and Accountability Act; federal privacy and security law for patient information (effective April 2003).

Periodontal charting components

Gingival changes; periodontal pocket readings; bleeding areas; exudate; recession; furcation involvement; tooth mobility; inadequate contact areas.

Contents included in dental hygiene progress notes

Treatment provided; patient’s response; compliance; communication with patient.

Contents not included in dental hygiene progress notes

Personal opinions; negative criticism; speculation about condition.

Gingival bleeding in SOAP notes

Documented in the Objective (O) section.

ADA Universal Numbering System

Tooth numbering system adopted by the American Dental Association; numbers teeth 1–32 in adults.

Palmer Notation System

Tooth numbering system using quadrant brackets to indicate tooth position within each quadrant.

Charting color for dental caries

Red; used to indicate carious lesions on a chart.