11. Consent, medicolegal and contemporary record keeping

Question 1

Purpose of a dental record

Answer 1

1. Establish diagnostic information and treatment provided
2. Defend against malpractice
3. Aid in identification of a person

Question 2

Who is the owner of a dental record?

Answer 2

The dentist

Question 3

General dental record retention guideline for children

Answer 3

28 years from date of birth

Question 4

General dental record retention guideline for adults

Answer 4

10 years

Question 5

What should not be included in a dental record

Answer 5

1. financial information

2. opinions, criticism or interpretations of patient statements

Question 6

EHR vs. EMR vs. EDR

Answer 6

EHR = health record across all settings and encounters

EMR = medical 
EDR = dental

Question 7

What is a PHR?

Answer 7

Personal Health Record

Designed to be accessed and managed by the patients

Question 8

What are advantages of EDR?

Answer 8

1. saves space and costs cover time
2. improved data tracking
3. improved coordination of care
4. more rapid communication
5. improved legibility

Question 9

What are disadvantages of EDR?

Answer 9

1. initial expense
2. learning curve
3. secure transmission of information

Question 10

Are there requirements for implementation of EDRs?

Answer 10

practitioners who accept MCD are subject to reimbursement adjustments after 2015 if they do not have EDRs

Question 11

What information should be collected in patient’s initial record?

Answer 11

1. name (legal and preferred)
2. gender
3. DOB
4. contact info (address, email, phone)
5. preferred method of contact
6. EM contact info
7. name of referring party
8. CC or reason for visit

Question 12

What are the elements of a medical history

Answer 12

1. medical conditions and/or illnesses
2. name/contact info of all providers
3. hospitalizations and surgeries
4. anesthesia experiences
5. current medications
6. allergies or reactions to meds
7. immunization status
8. review of systems
9. family history
10. social history
11. date of completion

Question 13

What are the elements of a dental history?

Answer 13

1. chief concern
2. previous dental experience
3. date of last dental visit/radiographs
4. oral hygiene practices
5. fluoride use and exposure history
6. dietary habits
7. oral habits
8. sports activities
9. previous orofacial trauma
10. TMJ history
11. family hx of caries

Question 14

What are the components of a comprehensive clinical examination?

Answer 14

1. general health and growth assessment
2. pain
3. EOE
4. TMJ
5. IOE
6. OH
7. Dentition
8. Occlusion
9. Radiographs (if indicated)
10. caries risk assessment
11. behavioral assessment

Question 15

What comprises the IOE?

Answer 15

tongue
floor of mouth 
palate and oropharynx 
buccal mucosa 
gingiva

Question 16

What comprises occlusion assessment

Answer 16

molar and canine relationship
overbite 
overjet 
midline 
facial profiel 
presence and descriptions of crossbites
crowding/spacing

Question 17

What comprises the hard tissue exam

Answer 17

teeth present
morphology
demineralization and cavitations
exciting restorations/appliances

Question 18

What should be included in a treatment plan

Answer 18

problem list/diagnoses 
tooth by tooth plan 
sequence of treatment by priority 
anticipated plan for behavior management 
preventive plan 
consultations (when appropriate)
pre and post op instructions 
alternatives to treatment

Question 19

T/F preventive and recall exams must contain same information as a new patient exam

Answer 19

True