Dental Emergencies and Records

Question 1

What is a dental record

Answer 1

The complete length of treatment of everyone individually

Question 2

Permanent record

Answer 2

Personal and legal documentation of the patient

Question 3

Privacy

Answer 3

HIPAA requires that all dental practices today have a
written privacy policy

Question 4

Quality assurance

Answer 4

Primary source of information used by the dental team to
determine the overall quality of care the patient has
received

Question 5

Risk Management

Answer 5

Proper documentation helps avoid litigation

Question 6

Who owns the patients records?

Answer 6

The dentists

Question 7

Entering Data in a Patient Record

Answer 7

1. Every entry in a chart should be made as if the chart will be seen in a court of law
2. At the conclusion of a procedure, the details of what was accomplished will be entered in the “Progress Notes” section
3. If corrections are necessary, incorrect information MUST be preserved and not deleted. Follow specific guidelines for paper and electronic records.

Question 8

Documentation

Answer 8

1. Documentation completed during or immediately following a patient visit, sometimes referred to as a progress note, is a chronologic history of treatment received by the patient during each appointment CPDH pg 166).

Question 9

Documentation

Answer 9

1. Each entry in the patient record is dated and signed by the clinician.
2. Only standard medical and dental abbreviations and symbols should be used, such as those recommended by the CDA
3. If the office or clinic has preferred abbreviations or symbols, they should be documented in an office manual. (SAIT Clinical Manual has a list of approved for use in our dental clinic).
4. Remember to be objective in recording accurate patient information and treatment.
5. The chart record is a legal document and could be used in a malpractice complaint.
6. HIPA rules also allow the patient to request a copy of their records.

Question 10

PARTS

P

Answer 10

Problem and/or Procedure: what procedure/treatment are you planning on doing today? Identify any problems the patient may be concerned about

Question 11

PARTS

A

Answer 11

Assessment: medical history update and notes about the patient’s health, including oral health and vital signs. Clinical Observations

Question 12

PARTS

R

Answer 12

Requisitions/recommendations and/or Prescriptions: local anesthetics used, medications or N/A if not applicable

Question 13

PARTS

T

Answer 13

Treatment: document the procedures that were completed at the appointment

Question 14

PARTS

S

Answer 14

Strategy: What is the plan following this appointment