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
What kind of factor influence is describe
Preferences
Motivation
Systemic health
Emotional status
Financial capabilities
Functional
Esthetic
Technical demands
Patient factor
Which factor influence is describe
Ethically and professionally responsible
Knowledge
Experience
Training
Availability of specialists
Laboratory support
Dentist factor
What is the treatment plan sequencing
1) process of scheduling the needed procedures into a time frame
2) sequenced in phase
3) what the patient need most is performed first
What are the phases of treatment planning
Urgent phase
Control phase
Re-evaluation phase
Definitive phase
Maintenance phase
It begins with a thorough review of the patients medical condtion and history, swellinh, pain, bleeding or infection
Urgent phase
How does control phase works
1) eliminate active disease such as caries and inflammation
2) remove conditions preventing maintenance
3) eliminate potential causes of disease
4) begin preventive dentistry activities
A phase where extraction, endodontics, periodontsl debridement and scaling , occlusal adjustment as needed, replacement or repair of defective restorations such as those with gingival overhangs, caries removal, use of caries control measures
Control phase
A phase that allows for resolution of inflammation and time of healing, home care habits are reinforced, motivation for further treatment, initial treatment and pulpal responses aremre evaluated
Re evaluation phase
A phase where endodontic, periodontic, orthodontic, oral surgery, operative , fixed or removable partial denture
Definitive phase
A phase where may reveal the need for adjustments to prevent future breakdown, provide an opportunity to reinforce home care, recall frequency
Maintenance phase
All activities from the initial treatment plan to the final treatment plan that is examination, diagnosis and final treatment should be maintained in the form of record.
Maintenance of the records also becomes a legal document in support of a particular action a dentist may take while rendering a treatment
This record nust be dated, with the headjngs made chronologically
Treatment record
What are the Interdisciplinary considerations in operative treatment planning
Endodontic
Periodontic
Othodontic
Oral Surgery
Occlusion
Fixed and removable prosthodontics
