Ch. 10 Documentation For Dental Hygiene Care Flashcards
Components of a Patient Record
- Signed acknowledgment of information for privacy measures
- Medical history and vitals
- Dental and psychosocial history
- Risk assessment
- Clinical assessment (dental charting, perio exam, i/o images, X-rays)
- Diagnosis and prognosis
- Tx recs, record of discussion w/ pt about options and written tx plan
- Informed consent/refusal
- Tx notes for each visit
When applicable:
Surgery anesthesia records
Study models
Ortho records
Lab order and results
Referral/ consult medical doc or dental specialist
Forms of Charting
Anatomic
Geometric
HIPAA
Health insurance and portability accountability act
1996. Dental in 2003
Pt rights
Responsibilities of health care facilities and providers
What is documented on an e/o I/o exam?
Any slight deviation from normal should be entered with a detailed description
UNS
Perm 1-32
Primary A-T
Begin in upper right to lower left
International (INS)
2 digits, quad then tooth number
Quads = 1-4
Teeth numbered 1-8 from midline
Palmer
1-8 from midline
Primary teeth A-E
Quads designated using vertical/horizontal lines
Anatomic Charting
Drawings of teeth, perio and dental
Shows visual and complete teeth
Geometric Charting
Diagrammatic representation
Provides space to record findings for each tooth
Ex: plaque score (disclosed biofilm) for personal teaching disease control
Odontogram
Intra oral findings and radiographs
Items to be charted for periodontal records
- Gingival margin and mucogingival lines
- Probing depth
- Recession
- Furcation involvement
- Mobility and Fremitus of teeth
Stains
Extrinsic: can be removed
Coffee, wine, etc
Intrinsic: can not be removed
During development
Medicine
Systematic Documentation for pt visits
SARP
SOAP
Summary
Assessment
Recommendation
Plan
Subjective
Objective
Assess
Plan
