Clinical Documentation

Question 0

Components of Clinical Records

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Answer 0

Data collection
1) CC or RFA
2) Full medical, dental and social history
3) Emergency examination, recording that it is a limited examination
and comprehensive examination will be require in the future
- Odontogram, Perio-chart, vitality tests, signs and symptoms.
4) Comprehensive oral examination which includes
- Can also include the above
- IO/EO
- Dietary or salivary examinations
- Study models, radiographs, photographs, drawings
-

Question 1

Purpose of Clinical Notes:

Answer 1

• Allows for delivery of high quality, comprehensive care by making
  detailed and relevant notes on the patient that will be readily
  available for treating practitioners.
• Assist in efficient and complete transfer of care if another practitioner
  is assuming the patient’s treatment
• For forensic purposes
• For teaching, education and research purposes
• For medico-legal purposes. (Records should be kept at a minimum of
  7yrs, 10 yrs to be absolutely safe)

Question 2

Components of Clinical Records

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Answer 2

Data Assessment

1) Diagnosis & Prognosis
2) Treatment plan
- All possible treatment options
- Time involved
- Cost
- Number of appointments
- Need for specialist intervention
- Possible complications and difficulties

Question 3

Components of Clinical Records

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Answer 3

Discussion & Decision

• Basically includes everything in Data Assessment +
• Patient expectations (outcome and cost)

Question 4

Components of Clinical Records

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Answer 4

Consent
- A contractual agreement that states that the patient has understood
the information you have presented (treatment options, adverse
events, costs and etc) and has given you permission to perform the
discussed procedures.
- More on informed consent in later cards.

Question 5

Components of Clinical Records

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Answer 5

Contractual Items
- Items and documents relevant to the dentist/patient contract
- E.g. if patient decides to refuse of cease treatment, if practitioner is
no longer able to provide treatment.
- Any information given to patient on continuation of treatment
elsewhere should also be retained.

Question 6

Components of Clinical Records

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Answer 6

Treatment

- Bulk of clinical notes are the treatment progress notes.

Question 7

Components of Clinical Records

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Answer 7

Unexpected
- Adverse outcomes or unexpected complications are to be recorded
- Full record of patient being informed, the any information they are
given (including options, additional cost and treatment)

Question 8

Components of Clinical Records

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Answer 8

Other
- Full details of other occurrences or discussion that may have
occurred which may relate to the patient’s wellbeing or treatment.
- May include financial statements, quotes, receipts.

Question 9

General Principles of Clinical Records

Answer 9

• Made at time of appointment
• Chronological order
• Accurate and concise
• Readily understandable by third parties
• Retrievable when required
• Stored securely and safeguarded against loss or damage
• Correction to records must not remove original information
• Must be objective and unemotional