DENTAL CHARTING Flashcards
CONSIST OF DOCUMENTS RELATED TO THE HISTORY OF PRESENT ILLNESS, CLINICAL EXAMINATION, DIAGNOSIS, TREATMENT DONE AND THE PROGNOSIS
Dental records
REQUARING PRACTITIONERS OF DENTISTRY TO KEEP RECORDS OF THEIR PATIENTS.
PD No. 1575, s. 1978
PD No. 1575, s. 1978 was signed on and by?
JUNE 11, 1978, by. PRES. FERDINAND MARCOS
WHICH SECTION IN PD NO.1575 S. 1978 STATES THAT
“ IT SHALL BE OBLIGATORY UPON ALL PRACTITIONERS OF DENTISTRY TO KEEP AND MAINTAIN AN ACCURATE AND COMPLETE RECORD OF THE PATIENTS WHICH SHALL INCLUDE A HISTORY AND DESCRIPTION OF THE PATIENTS DENTITION AND THE TREATMENTS MADE THEREON “
Section 1
Which section states “ upon the lapse of ten years from the last entry, dental practitioners shall turn oved the dental records of their parienrs to the National Bureau of Investigation for record purposes. Provided, that the said practitioners may retain copies thereof for their own files
Section 2
Which section states “ any violation of the provisions of decree shall be punished by a fine of not less than one thousand pesos nor more than thousand pesos
Section 3
What are the characteristics of a dental record
Uncomplicated
Comprehensive
Accessible
Current
What are the importance of a comphrehensive dental record / treatment plan
Proper care
Third party communication
Practice audits and quality assessment
Legal proceedings
Forencsic uses
Carefully sequenced series of services
Designed to eliminate or control etiologic factors
Repair existing damage and
Create a functional , maintainable environment
Treatment Plan
What are sound treatment plan
Thorough patient evaluation
Dentist expertise
Understanding of indications and contraindications
A prediction of the patients response to treatment
Steps in developing a treatment plan
1) examination and problem identification
2) decision to recommendmintervention
3)identification of treatment alternatives
4) selection of treatment with the patients involvement
It depends on a determination that a tooth is diseased, a restoration defective, the tooth or restoratiin is at some increased risk of further deterioration if intervention does not occur, if any of these conditions exist, intervention is reccommended to the patient
Deciding to intervene
Establish the list of one or more reasonable interventions from the set of the possible alternatives.
Treatment alternatives for a specific condition
A restoration is defective
Chemotherapeutics
Recontouring defective restorations
Repair
Restore
Identification of treatment alternatives
Consult the patient
Reasonable treatment alternatives
Risks
Benefits
Fully inform
Select the course of action
Selection of the treatment
What are the 2 factors that influence treatment plan?
Patient factor
Dentist factor