Da 3 Recordkeeping

Question 1

Purposes of Dental Records

Answer 1

provide an accurate patient’s general health,
oral and dental status
patient concerns

Question 2

Is it appropriate to share dental /medical records?

Answer 2

no, info is confidential

patient consent= sharing records to health professionals

Question 3

CDSBC 4 general recordkeeping principles

Answer 3

1. all entries dated and recorded by ink
2. all entries signed
3. Radiographs and diagnostic aid should be labelled
4. All treatments, alternatives, risks and limitations be provided to patient

Question 4

2 questions for Updating the Medical History

Answer 4

Any changes in health since last visit?

Any new meds taken?

Question 5

. What does PIPA stand for

Answer 5

Personal Information Protection Act of British Columbia

Question 6

PIPA purspose

Answer 6

regulates the use and disclosure of personal information
Privacy Officer(PO) is assigned to this role

Question 7

Diagnosis

Answer 7

Diagnosis-collected during the examination

Question 8

Treatment plan

Answer 8

Treatment plan -recommended and based on medical and dental history

Question 9

2 things included in Clinical Progress Notes are

Answer 9

Date

Clinicians Identity

Question 10

disclosing or transferring documents requires

Answer 10

Patient consent

Question 11

Who owns the patient charts?

Answer 11

Chart Belongs to Dentist

info=patient’s

Question 12

Records AFTER June 2013 kept for

Answer 12

kept for 16 years

Question 13

Records BEFORE june 2013 kept for

Answer 13

kept for 31 years

Question 14

Risk Management

Answer 14

procedures and practices that are used

to avoid lawsuits.

Question 15

Good records ensure:

Answer 15

good patient care
consistent treatment
accurate patient assessment

Question 16

Patient info Record

Answer 16

before appt
updated regularly
singed if minor

Question 17

Clinical records

Answer 17

accurate and comprehensive legal record

of a patients oral and general health

Question 18

Business and Financial Records

Answer 18

practice record- fees charged/ receipts

Income Tax Act.

Question 19

Drug Records include

Answer 19

Drug name
strength /quantity
onsite meds

Question 20

FOIPPA

Answer 20

Freedom of Information and Protection of

Privacy Act

Question 21

FOIPPA regualtes

Answer 21

disclosure of personal information by
public bodies
E.G VCC

Question 22

Basic Filing Systems used in Dental offices

Answer 22

Alphabetical
 Color coding-
 Numerical-
 Chronological
Electronic

Question 23

Acitve VS Inactive patients

Answer 23

Active= 2-3 yrs
Inactive = 3+ no seen