Dental Emergencies & Records - Outcome 1

Question 1

Freedom of Information and Protection of Privacy Act (FOIP) (Public - in Alberta) (October 1, 1995)

Answer 1

Protect personal information in the custody or control of public bodies such as:
Schools, Government agencies, health care bodies

Question 2

Health Information Act (HIA) (Public or Private in Alberta) (April 25, 2001)

Answer 2

Protects health information of individuals in the custody or control of custodians in private or public sector
Covers custodians (doctors, dentists, hygienists)
Also covers affiliates (assistants, receptionists, etc.)

Question 3

Personal Information Protection and Electronic Documents Act (PIPEDA) (Private - Federal) (January 1, 2001)

Answer 3

Sets national standard for privacy practices in the private sector
applies to every organization across Canada when collecting, using, or disclosing personal information while carrying out a commercial activity within a province unless a province passes legislation that is substantially similar to PIPEDA (based on the same purposes and rules). For Federally regulated - (banks, telephone companies) located in AB

Question 4

Personal Information Privacy Act (PIPA) (Private - Alberta) (January 1, 2004)

Answer 4

Protects personal information in custody or control of a private sector organization (such as: Dental clinics, private schools, non-for-profit organizations)

Question 5

Health Professions Act (HPA) (Public)

Answer 5

governs the practice of 32 regulated health professions, sets out standard processes for colleges for registration, continuing competence, complaints and discipline and establishes a board that advises the Minister

Under HPA, health professionals are governed by regulatory bodies called “colleges” in Alberta for us DA’s it is the CADA (College of Alberta Dental Assistants)

Question 6

The Principles of HIA

Answer 6

The HIA applies to health information resulting from health services provided by a custodian.
It is a principle of the HIA that access to records be given unless the Act specifically allows the record to be withheld. This right of access is balanced by the need to protect individual privacy.
The HIA controls how health information is collected, used, and disclosed. It prevents another person from seeing an individual’s health information without their consent while enabling health information to be shared and accessed to provide health services and manage the health system.
Individuals can ask to see or have a copy of their health records if a custodian holds them.
Individuals have the right to request that their health information be corrected if it is not accurate. This is not an absolute right, and a request to correct information may be turned down.
The Act provides for review by the Information and Privacy Commissioner if individuals are not satisfied with the decisions of custodians in response to requests made under the Act. In cases where correction of health information has been refused, an individual may request a review of the decision by the Commissioner OR they may have a statement of disagreement attached to their health record.
Individuals can also complain to the Commissioner of the OIPC if they believe their health information has been collected, used, or disclosed in violation of the HIA (Alberta Queen’s Printer, 2022).

Question 7

The Principles of FOIP

Answer 7

The FOIP Act legislates that applicants have the right to access records held by the government. It is a principle of the Act that access to records be given unless the Act expressly allows the record to be withheld. The right to access is balanced by the need to protect individual privacy.
The Act controls how personal information is collected, used, and disclosed. It prevents another person from seeing your personal information without consent.
Individuals can ask to see records held by the government, including personal information. Individuals have the right to request that personal information be corrected if it is not accurate.
The Act provides for review by the Information and Privacy Commissioner if individuals are not satisfied with the decisions of public bodies in response to requests made under the Act.
Individuals can also complain to the Commissioner of the OIPC if they believe their personal information has been collected, used, or disclosed in violation of the Act (Alberta Queen’s Printer, 2023).

Question 8

Principles of PIPA

Answer 8

Personal information in the custody or control of private sector organizations as it relates to commercial transactions or activities will be subject to the Act.
Personal employee information will also be covered by PIPA.
PIPA will allow individuals to request access to their own personal information, including their personal employee information, and to request that personal information be corrected if the accuracy of the information is disputed.
Just as the Information and Privacy Commissioner may review decisions by organizations and agencies subject to the Freedom of Information and Protection of Privacy Act or the Health Information Act, PIPA also allows the Commissioner to review the decisions of private sector organizations to deny an individual access to their own personal information, or to refuse a request for correction to their own personal information.
Individuals may also make a complaint to the Commissioner if they believe their personal information has been collected, used, or disclosed without proper authority or without their consent (Alberta Queen’s Printer, 2022a).

Question 9

The Personal Information Protection and Electronic Documents Act

Answer 9

The Personal Information Protection and Electronic Documents Act (PIPEDA), sets national standards for privacy practices in the private sector. Alberta and British Columbia have both passed similar laws, known in each province as the PIPA (Office of the Privacy Commissioner of Canada, [OIPC], 2004).
Both the federal Act, PIPEDA, and Alberta’s PIPA focus on protecting personal information in the private sector.
PIPEDA applies to every organization across Canada when collecting, using, or disclosing personal information while carrying out a commercial activity within a province unless a province passes legislation that is substantially similar to PIPEDA (based on the same purposes and rules).

Where health information is being transferred across provincial boundaries in relation to commercial activity, such as in the case of obtaining payment from an insurance company located outside of Alberta, the provisions of the federal Personal Information Protection and Electronic Documents Act (PIPEDA) may apply (CDSA, 2016a).

Question 10

Privacy is..

Answer 10

Collecting, using, disclosing, and safeguarding, personal info

is the right of an individual to have some control over how his or her personal health information is collected, used, and/or disclosed and is governed by applicable privacy legislation, including Alberta’s Health Information Act (HIA) (Government of Alberta, 2021a).

Patients have a right to keep their health information private and control who can access it. Patients also have the right to:

Receive a copy of personal health records.
Ask to change incorrect or incomplete information.

Question 11

Confidentiality is..

Answer 11

Keep info secret.
Do not tell anybody or else you lose trust.

is the obligation of a person or organization to protect the information entrusted to it (CDSA, 2016a). Discussion about a patient’s personal information, medical history, or treatment must be held in confidence and is not to be shared with anyone. This includes spouses, family, friends, or other dental healthcare professionals who are not directly involved in a patient’s care — to do so is a breach of patient confidentiality. You cannot reveal the identity of a patient or any other information from a patient’s record without the patient’s consent (Robinson, 2024). Breaches of confidentiality can result in a lawsuit against you as a dental assistant.

Question 12

Autonomy

Answer 12

self-determination, - a persons choice to think, judge, and act independently without unwarranted influence

Question 13

beneficence

Answer 13

doing good for others

Question 14

code of ethics

Answer 14

• Outlines the responsibility of the dental assistant to the patient to abide by all applicable legislation
  governing practice, privacy, confidentiality, and human rights (CADA, 2024a).
• The Code of Ethics goes further to provide ethical statements meant to provide guidance to ensure that a patient’s privacy is maintained. It is unethical to disclose any personal information about a patient.

Question 15

ethics

Answer 15

moral standards of conduct: rules or principles that govern proper conduct

Question 16

justice

Answer 16

fair treatment of the patient

Question 17

nonmaleficence

Answer 17

of no harm to the patient

Question 18

veracity

Answer 18

truthfulness; not lying to the patient

Question 19

CADA Code of Ethics

Answer 19

1.1 Generally

a) The health and well-being of the patient is the priority in all professional interactions.

b) Dental Assistants:

i. take professional responsibility for all professional actions;

ii. engage in best practices;

iii. competently apply knowledge and skills to avoid causing harm;

iv. if harm occurs, disclose the issue to the patient and supervisor as soon as practicable and take appropriate steps to minimize the harm; and,

v. evaluate processes to prevent recurrence.

c) Dental Assistants are knowledgeable of and practice to the current standard of care, seeking sound scientific information to support practice decisions. The current standard of care encompasses, but is not limited to, patient autonomy, current infection prevention and control procedures, occupational health and safety requirements and evidence-based use of appropriate procedures and materials.

d) Services are provided without bias or discrimination and communications are respectful and truthful.

Question 20

What is health care information?

Answer 20

Diagnostic, treatment and care information,
including health service provider information; and
* Registration information, including a person’s personal health number

Question 21

What is a “health service”?

Answer 21

• The Health Information Act defines a “Health Service” as a service which provides any of the following to an individual:
  ◦ protecting, promoting, or maintaining physical and mental health;
  ◦ preventing illness;
  ◦ diagnosing and treating illness;
  ◦ rehabilitation; or
  ◦ caring for the health needs of the ill, disabled, injured or dying

Question 22

General Principle of Privacy Laws

Answer 22

Right of access vs. right to privacy
* Control collection, use and disclosure
* The role of patient consent – when?
* A person must be allowed to view or obtain a copy of their records
◦ Note that this not have to happen at the moment of the request
◦ Dental offices have 30 day to comply

Question 23

Collection & Use

Answer 23

• You may only use the patient’s information for the purpose that it was provided at the time that you collected the information from the patient
  (Easton, 2020).
• You may need consent from the patient to use their information.
  ◦ If you intend to use the patient’s information for a purpose that is different from the original purpose that
  the information was collected for, you most likely need to receive the patient’s consent to do this

Question 24

Disclosure

Answer 24

The disclosure of information occurs when it is shared outside of the health information custodian that collected it (Easton, 2020).
* Disclosure also occurs when personal health information is shared for a reason that differs from the reason why the information was collected
(Easton, 2020).

Question 25

HIA Information Managers

Answer 25

Information managers are authorized through
written agreement (Information Manager
Agreement [IMA]) by a custodian to use health information in the following ways:
◦ Process, store, retrieve or dispose information;
◦ Strip, encode or otherwise transform information; or,
◦ Provide information management or information technology services (Easton, 2020)

Question 26

Privacy Officers

Answer 26

Each custodian must designate a Privacy Officer.
The Privacy Officer’s role is to:
◦ Monitor who can access health information.
◦ Identify privacy compliance issues.
◦ Ensure privacy and security policies and procedures are followed.
◦ Ensure staff and contractors are aware of their responsibilities and duties.
◦ Provide advice and interpretation of the Health Information Act and respond to requests for access to or correction of health information

Question 27

Information & Privacy Commissioner

Answer 27

• Privacy law experts – they are the authority if you are uncertain
• They conduct and review investigations of
  breaches (and much more)
  ◦ Under the Health Information Act, it is mandatory to report a breach of privacy, no matter the circumstances, to the OIPC

Question 28

Standards of Practice - CADA

Answer 28

CADA’s Standards of Practice state that dental assistants must understand the requirements of the Health Information Act and the custodian’s policies and procedures for protecting patient’s personal and health information
* Custodians are responsible for implementing security measures, policies, and protocols that affiliates must abide by.
* Revealing information about a patient is in
contravention of the HIA.

Question 29

Confidentiality exceptions

Answer 29

There are legal requirements mandating that dental healthcare providers report cases of suspected child or elder abuse to protect those individuals from harm (Robinson, 2024).
* There are also legal requirements that exist to report communicable diseases that have an effect on the health of the public

Question 30

Administrative Safeguards

Answer 30

• policies and procedures,
• oaths of confidentiality,
• privacy awareness training programs,
• code of conduct,
• and access request forms

Question 31

Physical Safeguards

Answer 31

Physical safeguards refer to the security that we use in locations where personal health information is maintained.
◦ locked cabinets;
◦ key control;
◦ motion detectors and other intrusion alarm systems;
◦ fire suppression;
◦ secure shredding; and,
◦ fax machines in secure locations

Question 32

Technical Safeguards

Answer 32

Technical safeguards include computer
systems and controls like complex password requirements, audit
logs, backup, role based
access permissions etc.

Question 33

Use of Personal Health Info

Answer 33

You may only use the patient’s information for the purpose that it was provided at the time that you collected the information from the patient (Eaton, 2020).
* If you intend to use the patient’s information for a purpose that is different from the original purpose that the information was collected for, you likely need to receive the patient’s consent to do this
Viewing personal health information is the
same as using personal health information

• You may view personal health
  information only when you have a need to
  know that information to provide a health
  service or to do your job (Eaton, 2020).
• If you view personal health information “just to see” and don’t have an authorized need to access the information, this is a privacy breach

Question 34

Access Request

Answer 34

When a patient requests to have a copy of
their own records, this is an access request,
not a disclosure

Question 35

The Patient Record

Answer 35

The patient record is the principal document containing critical information you will need to manage each patient in the dental practice
* Whether you are communicating with a
patient by phone or in person, the patient
record must be available for reference
* A patient’s record is organized in a specific
order to allow the dental team to move from the patient’s personal information, to the diagnostic findings, and then finally the
documentation of treatment

Question 36

Importance of a Patient Record

Answer 36

Guides/directs dental care
* Basis for diagnosis and treatment plan
◦ Dentist
◦ Dental hygienist
* Evaluates response to treatment
* Insurance audits
* Evidence in a court of law
* Taxes
* Assists in forensic evidence

Question 37

Patient Registration Form

Answer 37

• Patient information including full name, date of birth, address, telephone numbers (home,
  cell, work), employment information, spousal information, and emergency contact
• Insurance information
• Responsible party indicates who will pay for treatment
• Patient signature and date

Question 38

Other Forms completed by patient (other then registration form)

Answer 38

Medical/Dental History Form
◦ provides an overview of the patient’s past medical and dental health conditions.
* Patient Consents - a) Disclosure (release of information) b) Treatment (informed consent)
* Privacy Policies
* Financial Policies

Question 39

Forms completed by Dental Staff

Answer 39

Diagnostic forms
◦ Physical Examination form which most often is used to record the patient’s vital signs

◦ Radiographic Examination

◦ Clinical Examination form which records the results of the intra- and extra-oral examination
Patient’s name and date of examination Charting of existing
restorations and present conditions
a) Extraoral Examination:
i. Findings of temporomandibular joint
b) Intraoral Examination
i. Charting of periodontal conditions
ii. Patient’s chief complaint
iii. Findings of occlusal evaluations
iv. evaluations
v. Comments

Informed Consent
◦ for specific treatment to be undertaken, such as consent to remove an infected tooth

Informed Consent:
a) Related to a specific treatment or procedure, provides the patient with the expected outcomes of treatment
and describes any possible complications that might occur
b) Commonly used for invasive or extensive treatment, such as in specialty procedures

• Treatment Plans
  ◦ records the details of any planned treatment
  a) Record the plan of care on the treatment plan form
  b) Properly sequence to address all problems that were identified during examination and diagnosis portions of the
  patient visit.
  c) Treatment plan may change course if financial arrangements become a factor
• Progress Notes - PARTS
  ◦ a record of actual treatment provided to the patient

Question 40

General Rules of Dental Record

Answer 40

Documentation should occur during or immediately after patient visits
Documentation should be made in chronological order
The use of unique abbreviations that can not be easily understood by others should not be used
Never include speculation or derogatory statements in a dental record

Question 41

How to maintain a legal document

Answer 41

Each component of the patient’s record
needs to be marked with patient’s name
* Health histories and vital signs need to be
updated regularly and should be
documented comprehensively
Use permanent pen
 Do not change pens in middle of an entry
* Write neatly and clearly
 For mistakes stroke out with one clean line, initial and date error.
 Scribbling incorrect information and/or erasing/using “white out” cannot be defended in a court of law.
* Ensure information is relevant and accurate
-Use uniform terminology and abbreviations
Record immediately and in order of treatment
 Ensure warning/caution indicators stand out
Pre-medications
Allergies
Phobias/Anxiety
 Whomever provided the service records in the chart
 All records must be dated, signed and/or initialed by the person who is recording the record

Question 42

Infection Prevention Control for Records

Answer 42

• Paper records
• This may include using plastic barriers to
  cover papers and pens (Boyd & Mallonee,
  2023).
• Electronic records
  ◦ plastic barriers for computer keyboards
  and mouse, as well as disinfection of
  chairside monitors (Boyd & Mallonee,
  2023).

Question 43

Systematic Chart Entries

Answer 43

Assures that no details are missing from the patient’s record,
* Aids in ensuring records are sufficiently detailed,
* the use of acronyms such as or can provide guidance and uniformity in recordkeeping protocols

Question 44

RATPP (systematic chart entry)

Answer 44

RATPP
◦ R-reason
◦ A-anesthetic used
◦ T-treatment,
◦ P-post-operative care
◦ P-plan for next visit

Question 45

SOAP (systematic chart entry)

Answer 45

S.O.A.P
◦ S-subjective
◦ O-objective
◦ A-assessment
◦ P -plan

Question 46

PARTS **systematic chart entry USED BY SAIT*

Answer 46

PARTS
◦ P- problem or procedure
◦ A- assessment
◦ R- recommendations/prescriptions
◦ T- treatment
◦ S-subsequent advice

Question 47

What form records existing conditions in
patient’s oral cavity?

Answer 47

Diagnostic Form / Clinical Examination Forms

Question 48

What form may include information about
patient’s past experiences with dental
treatment?

Answer 48

Dental History

Question 49

What record’s the treatment provided during each visit?

Answer 49

Progress notes

Question 50

What form informs dental team of conditions that could be life-threatening to patient during treatment?

Answer 50

Medical History

Question 51

What form describes expected outcomes of
treatment along with possible complications?

Answer 51

Informed Consent

Question 52

PARTS details

Answer 52

PARTS notes are used in the SAIT DA program to standardize daily
chart entries:
P = Problem and/or Procedure: what procedure/treatment are you planning
on doing today? Identify any problems the patient may be concerned about.

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

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

T = Treatment: document the procedures that were completed at the appointment

S = Strategy/Subsequent advice: What is the plan following this appointment

Comments: This is where you put any information that does not fit into any
of the above, but that you feel it is important to make note of.

Question 53

Written Chart benefits

Answer 53

• If there is power or software issue the chart is still accessible
• File is portable for viewing in rooms without a computer

Question 54

Electronic Chart benefits

Answer 54

Standardize terms
* Increased speed of entry
* Encourages more detailed entries
* Increased legibility
* Introduces new ways to share information
* Maintains digital radiographs and photographs within record

Question 55

Filing Patient Records

Answer 55

• Written
  ◦ In an area accessible
  only by authorized
  personnel
  ◦ Locked drawers/room
• Electronic
  ◦ Requires more
  computers for
  authorized personnel
  ◦ Password protected

Question 56

Record Keeping

Answer 56

• Detailed records are essential for continuity of care, safe treatment of patients, and for the protection of the dental healthcare professional.
• The patient record must contain sufficient
  information to provide a record of informed
  consent, diagnosis, treatment plan, care
  provided, and postoperative instructions such that another health care provider can continue care

Question 57

Chart Audits

Answer 57

A chart audit is a method of reviewing
documentation techniques. It is performed to ensure accountability and competent record keeping and quality assurance of patient care

Question 58

Retention of Dental Records

Answer 58

In Alberta, patient records for adults must
remain accessible for a minimum period of ten (10) years following the date of
the last service, and patient records for
minors must be accessible for a minimum
period of ten (10) years past the patient’s age of majority

Question 59

Appointment Records

Answer 59

A record of appointments showing for each
day the names of patients who received
professional services must be kept for a
period of at least two (2) years

Question 60

Privacy Breaches

Answer 60

Health Information has been or may be
accessed by a person
* Health Information has been or may be
disclosed to a person
* Health Information has been misused or will be misused
* The breach could be used for identity theft or to commit fraud
* The breach causes embarrassment
* The breach causes physical, mental, or
financial harm
* The breach damage an individual’s reputation
* The breach adversely affects the provision of a health service to the individual

Question 61

Privacy Impact Assessment

Answer 61

A privacy impact assessment (PIA) is a
process of analysis that helps custodians to
identify and address potential privacy risks
that may occur in the operation of a new or
redesigned project.
* A PIA is meant for proposed legislative
schemes, administrative practices, and/or
information systems that relate to the
collection, use, or disclosure of individually
identifying personal or health information

Question 62

The Health Information Act of Alberta defines “record”…..

Answer 62

The Health Information Act of Alberta defines “record” to mean health information in any form and includes notes, images, audiovisual recordings, x-rays, books, documents, maps, drawings, photographs, letters, vouchers, papers, and other information about an individual that is collected when a health service is provided to the individual, that is written, photographed, recorded or stored in any manner

Question 63

Each component of the patient record should be marked with…

Answer 63

patient identification and/or demographic information

Question 64

Remember, the dental record is.

Answer 64

1. A method of communication.
2. A legal document.

Question 65

Personal Information Protection and Electronic Documents Act (PIPEDA)

Answer 65

The Personal Information Protection and Electronic Documents Act (PIPEDA), sets national standards for privacy practices in the private sector. Alberta and British Columbia have both passed similar laws, known in each province as the PIPA (Office of the Privacy Commissioner of Canada, [OIPC], 2004).
Both the federal Act, PIPEDA, and Alberta’s PIPA focus on protecting personal information in the private sector.
PIPEDA applies to every organization across Canada when collecting, using, or disclosing personal information while carrying out a commercial activity within a province unless a province passes legislation that is substantially similar to PIPEDA (based on the same purposes and rules).

Where health information is being transferred across provincial boundaries in relation to commercial activity, such as in the case of obtaining payment from an insurance company located outside of Alberta, the provisions of the federal Personal Information Protection and Electronic Documents Act (PIPEDA) may apply (CDSA, 2016a).

Question 66

Dental Records

Answer 66

Maintaining accurate and complete dental records is essential to any dental practice and is a basic requirement of providing patient care. Information about the patient’s general and oral health must be obtained before a thorough diagnosis and treatment plan can be formulated. The patient’s dental record must be available for reference whenever you are communicating with the patient, be it in person, on the phone, speaking to another healthcare professional, or an insurance company (Robinson, 2024).
A dental record must record an accurate picture of the patient’s general health, oral/dental status, and any patient concerns and requests. It must include the clinical findings, diagnosis, proposed treatment plan, and treatment performed, as well as all supporting documentation including the informed consent process (CDSA, 2016).

The Health Information Act of Alberta defines “record” to mean health information in any form and includes notes, images, audiovisual recordings, x-rays, books, documents, maps, drawings, photographs, letters, vouchers, papers, and other information about an individual that is collected when a health service is provided to the individual, that is written, photographed, recorded or stored in any manner

Question 67

a dental record consists of…

Answer 67

A dental record, therefore, consists of several different components, such as:
Required information

demographic information,
medical history and vital signs,
dental history,
risk assessment (e.g. periodontal, caries, oral cancer, tobacco and/or substance use and diabetes),
clinical assessment and diagnosis,
progress notes for each patient visit,
treatment recommendations and treatment plan,
informed consent, and
privacy and confidentiality measures (Boyd & Mallonee, 2023).
Additional components

study models,
orthodontic records,
laboratory orders and test results, and
referral records and copies of consultation with dental specialists or medical practitioners

Question 68

Accurate dental records are important for several reasons:

Answer 68

Provide a means of communication between members of the dental health team and the patient.
Facilitate treatment planning and continuity of care
The basis for the evaluation of the quality of care and effectiveness of patient care practices.
Data can be used in research and education.
Considered legal evidence in any legal or forensic situation

Question 69

Examples of forms used in a dental record:

Answer 69

Examples of forms used in a dental record:

patient registration
medical/dental history forms
consent forms
diagnostic information gathering forms
clinical examination forms
treatment plan forms
progress notes

Question 70

Privacy Breaches under the HIA

Answer 70

A privacy breach means a loss of, unauthorized access to, or unauthorized disclosure of individually identifying health information (Alberta Queen’s Printer, 2022). If a privacy breach occurs, and a custodian determines there is a risk of harm to the individual, the custodian must notify:

·Individual(s) affected,
·The Information and Privacy Commissioner, and
·The Minister of Health (Alberta Queen’s Printer, 2022).

Affiliates must also notify the custodian when a privacy breach occurs

Question 71

Risk of Harm - breaches

Answer 71

Health Information has been or may be accessed by a person
Health Information has been or may be disclosed to a person
Health Information has been misused or will be misused
The breach could be used for identity theft or to commit fraud
The breach causes embarrassment
The breach causes physical, mental, or financial harm
The breach damage an individual’s reputation
The breach adversely affects the provision of a health service to the individual (Office of the Information and Privacy Commissioner

Question 72

Electronic Records

Answer 72

Electronic Records
Computerized records have recently provided a quicker, more convenient, and better-organized replacement for written records (Boyd & Mallonee, 2023).
Electronic records must comply with all requirements of traditional paper records (CDSA, 2016).
Electronic records require computer terminals where only authorized personnel can access the required information (Boyd & Mallonee, 2023).
Dental personnel must have individual logins and passwords to access the data (CDSA, 2016).
Computer terminals should be directed away from the view of unauthorized persons (Boyd & Mallonee, 2023).
A variety of programs are available. Electronic records have the potential to:

standardize the terminology used for data entry,
improve efficiency - speed up entry of information and encourage more comprehensive information,
increased legibility
provide new ways for sharing information with dental specialists and other multidisciplinary team members
maintain digital radiographs and photographs within the patient record,
provide new ways of analyzing clinical information and treatment outcomes, and
provide easier and faster access to clinical information

Question 73

Written Records

Answer 73

Historically, dental healthcare records have been maintained in written form.
Handwritten records are to be recorded legibly and written in ink (Robinson, 2024)
Mistakes are corrected by placing a single line through the error and writing the correction rights after and signing (Boyd & Mallonee, 2023).
White-out should not be used in a written record (CDSA, 2016).
If a late entry is necessary, the new information should follow the most recent entry, it is to be noted as a late entry and should include the date and time that the late entry was made (Boyd & Mallonee, 2023).

Question 74

several essential components of a clinical record that include:

Answer 74

all entries on a patient record are dated;
all entries on a patient record are signed, initialed, or otherwise attributable to the writer and treatment provider;
all paper-based entries on a patient record are recorded by hand in permanent ink, typewritten, or printed from a digital file;
accurate general patient information that is periodically updated;
a medical history that is periodically updated and at a minimum verbally reviewed prior to each appointment and noted within the chart;
a dental history;
an accurate description of the conditions that are present on initial examination, including an entry such as “within normal limits (WNL)” or “no abnormalities detected (NAD)” where appropriate;
an accurate description of ongoing dental status at subsequent appointments;
a record of the significant findings of all supporting diagnostic aids, tests, or referrals such as radiographs, diagnostic casts/models, and reports from specialists;
all clinical diagnoses and treatment options;
a record identifying all reasonable treatment planning options including no treatment and that they were discussed with the patient;
the proposed and accepted treatment plan;
a notation and documentation that informed consent was obtained;
assurance that patient consent was obtained for the release of any and all patient information to a third party;
a description of all treatment that was performed, materials and drugs used, and where appropriate, the prognosis and outcome of the treatment;
details about referrals;
an accurate financial record;
the patient, caregiver, or guardians’ signature in most cases on the medical history, privacy policy, and informed consent documentation; and
a copy of all patient communications.

Question 75

Chart Audit

Answer 75

A chart audit is a method of reviewing documentation techniques. It is performed to ensure accountability and competent record-keeping and quality assurance of patient care.

Question 76

Filing Storage of Patient Record

Answer 76

In all storage systems, the privacy of a patient’s information must be respected.

For written records, a filing system is needed that provides accessibility to health records by authorized personnel. They are to be secured in a locked cabinet or room when staff is not on-site and able to monitor access (Boyd & Mallonee, 2023).

Electronic records must store the original data in a read-only format from within the dental program itself, but protect the data files for entry and alteration from the database. Electronic records must have backup files on a removable medium that allows for data recovery and provides by other means reasonable protection against loss, damage, and/or inaccessibility of patient information. The dental professional using the electronic record must be properly trained and have technical competence with the computer program (CDSA, 2016).

Dental records need to be securely stored for the appropriate length of time as determined and reasonable for business and legal purposes. In Alberta, patient records for adults must remain accessible for a minimum period of ten (10) years following the date of the last service, and patient records for minors must be accessible for a minimum period of ten (10) years past the patient’s age of majority. In the event of a patient becoming deceased, the retention period is not changed (CDSA, 2016). A record of appointments showing for each day the names of patients who received professional services must be kept for a period of at least two (2) years (CDSA, 2016).