Diagnostic Record Chapter 26&27 Flashcards
patient dental records must be
accurate, legible, organized and accessible
what are 3 record keeping principles
everything signed and dated, written in permanent ink(if paper), copies of patient communications and refferals
dental records are ____ and ___ documents
permanent and legal
in case of malpractice what forms prevent the dentist from being convicted
all forms present in chart
dental records are used in ___ sciences
forensic
how long are adult patient records kept before being destroyed
10 years from date of last visit
how long are minor patient records kept before being destroyed?
10 years from the date of patient turning 18
what is quality assurance
program in place to monitor and evaluate treatments occurring in offices etc, to ensure standards of quality are being met
Dental records are a form of
risk management
PHI
personal health information
PIPA
personal information protection act
Pipa is a ____ legislation
provincial
When has provincial legislation been effective since?
2004
PIPA governs the collection, use and disclosure of
personal information by organization in respect to rights of individuals and needs of organization
HIPAA
health insurance portability and accountability act
PIPEDA
personal information protection and electronic documents act
Pipeda is a ____ legislation
federal
Federal legislation has been in place since
2000
when is federal legislation in effect
when submitting patient info across provincial borders
PIPEDA is for
establishing rules governing collection, use and disclosure of personal info recognizing right to privacy
A patient chart is composed of
registration, consent, medical history, dental history, treatment plan, and treatment record forms
where are medical alert stickers placed in the chart
inside the chart to protect patient confidentiality
when are registration forms filled out
prior to first treatment at/prior to first visit
the form pertaining to a certain treatment is the
consent form
when are medical/dental update forms completed
after each visit
implied consent is
the patients actions dictate their consent
written consent is
the patient signs a document outlining treatment
informed consent is
the patient agrees after knowing all info regarding treatment
a patient refusal of treatment must be
signed and dated by patient, and doctor
which form is the most detailed in the chart
clinical examination form
what is a level 1 (emergency) treatment plan
takes care of immediate problems (knocked out tooth) mostly pain management though
what is a level 2 (standard) treatment plan
restores dentition back to “normal function” (restorations)
what is a level 3 (optimum) treatment plan
restores dentition to max. function (veneers, crowns, bridges)
progress notes are aka
treatment record
progress notes are written in chronological order and detail
date, tooth #, treatment completed, communication between patient
records are owned by who
the dentist and they can’t be removed from the office
how do you correct a mistake on a chart
with a single strike through mistake with date and initials next to it
chief complaint
the purpose of visit
data must be
written in blue/black ink, signed and dated, chronological order
BP
blood pressure
CC
chief complaint
CUD
complete upper denturee
CLD
complete lower denture
PUD
partial upper denture
PLD
partial lower denture
Abr
Abrasion
Acr
acrylic
Porc
Porcalin
Ven
Veneer
Ag
amalgam
comp
composite resin
Ant, Post
Anterior and posterior
Tx
treatment
Pt
patient
Attr
attrition
Ero
erosion
PMH
past medical history
PDH
Previous dental history
HPC
history of present condition
RCT
root canal treatment
abutment is the
tooth/root/ implant used as retention for a fixed or removable prosthesis
Diastema is the
abnormal open space between teeth
Hypoplasia
the undergrowth or abnormal development of tissue
Hyperplasia
overgrowth of tissue
Pontic
the artificial tooth replacing a natural tooth
mobility is
movement of a tooth in its socket
periodontal pockets are created when the
depth of sulcus exceeds 3mm
a restoration is AKA
a filling of amalgam or composite
a geometric odontogram is when
the structure of tooth is represented by a circle
a anatomic odontogram is when
structure of tooth is an accurate representation
what is a mirror used for
indirect vision and light reflection
an explorer is used for
detecting imperfections in enamel and restorations
probes are for
measuring depth of sulcus
radiography is used to identify
decay, defective restorations, pathology, periodontal condition, and developmental conditions
intra oral imaging is
a small camera used to display image/video of mouth on a screen for patient reassurance
intraoral/extraoral photography is
orthodox before and after shots
a palpation (extra oral) exam is
using fingers to feel texture/size of tmj,facial muscles, lymph nodes
types of patients
new, emergency, consulting, recall
a recall appointment is with the
hygienist
when palpating your looking for
shape, size,texture abnormalities
Class I cavitys
occlusal pits+fissures of posterior teeth
Buccal lingual pits molars
Lingual pits anterior maxillary teeth
Class II cavitys
mesial distal pits on molars
Class III cavitys
Mesial distal anterior teeth
Class IV cavitys
Mesial distal incisal anterior teeth
Class V Cavity
Cervical third of any tooth
Class IV Cavity
cusp tips, incisal edges
Amalgam is charted as
completely shaded in of connected surfaces in red or blue
Composite is charted as
Outline of connected surfaces in red or blue
Recurrent decay is charted
by outlining existing blue restoration with red
A red right angle triangle is known as
overhang, long side on affected tooth
Sealants are charted as
an S on occlusal surface, red or blue
A red circle at the apex of a root is a
abscess
How do you chart a root canal
by drawing a line down the root(s) in red or blue
Post and cores are charted as
line through centre of tooth with arrow on crown side in red or blue
Circling the cervical third and writing ABR in red is how to chart what
abrasion
To chart attrition you
draw a horizontal line on incisal/occlusal edge and write attr in red
A circle on the top of the tooth in red with Ero written is
erosion
Recession is charted by
drawing a line below gingival margin and writing amount receded in red
Furcation is charted how
by drawing symbol depending on class between roots in red
M1,M2, or M3 written in red would be
mobility
how would you chart over/under eruption
an arrow signifying over or under with amount above tooth in red
a semicircle arrow above a tooth is for
medial or distal rotation
drifting is charted as a
arrow pointing medial or distal above the tooth in red
pulp written above a tooth in red or blue is a
pulpotomy, only on primary teeth
a space maintainer is drawn as a
crown on adjacent tooth with bar the stretches across missing tooth in red or blue
an endentulous arch is a
blue X across affected arch
how would you chart a partially erupted tooth
circle all of tooth except half of crown and write PE in red
A fully red circled tooth indicates a
impacted tooth
A extraction is charted as a
single diagonal red line through tooth
a blue X through tooth indicates a
missing tooth
Crowns are charted by
outlining all surfaces of tooth (material dependant) in red or blue and writing material
PJC
porcelain jacket crown
PFM
porcelain fused to metal crown
Stainless steel crowns are charted as
outline all surfaces and write SS on occlusal in red or blue, mainly primary teeth after root canal
A only buccal, facial outline with Ven written in blue or red is a
Veneer
How would you chart a bridge
X through missing tooth, draw type of crown, connect with =, write material/type of bridge in red or blue
A Maryland bridge would be charted as
a fake tooth with wings cemented to linguals of adjacent teeth in red or blue
a 3 tooth cap over a missing tooth and 2 shaved down teeth is a
fixed bridge
what is the difference between and inlay and an onlay
inlays don’t have any cusps included
Inlay would be charted as
gold or porcelain, drawn as MOD in red or blue with material written above
an onlay is charted as
gold or porcelain, drawn as modb in red or blue with material written above
2 red vertical lines between teeth is known as
diastema
a red zigzag is a
fracture
how would you chart a CUD and CLD
line drawn below arch with lines attaching that extend through each tooth, in red or blue, write CUD or CLD
how would you chart a PUD and PLD
line drawn below arch connecting with lines extending though the missing teeth, write PUD or PLD in red or blue
blue or red horizontal lines through a root signifies a
implant
A fixed lingual retainer is drawn as
a line on lingual anterior teeth with dots on each end in red or blue
Periodontal probing is done to
measure how much epithelial attachment has been lost to disease
a probe measurement of 0-3mm is considered
healthy, recorded in blue or black ink
A probe measurement of 4mm or more is considered
diseased, recorded in red ink
how many probing measurements per tooth
6
Which readings are completed first when doing full dentition probe
facial/buccal readings
how is the dentition divided for periodontal probing
into sextants
the bleeding index is
how much bleeding is observed during probing
how is bleeding recorded on a periodontal chart
with a red * above the measurement
