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dental assisting mda > Diagnostic Record Chapter 26&27 > Flashcards

Diagnostic Record Chapter 26&27 Flashcards

1
Q

patient dental records must be

A

accurate, legible, organized and accessible

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2
Q

what are 3 record keeping principles

A

everything signed and dated, written in permanent ink(if paper), copies of patient communications and refferals

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3
Q

dental records are ____ and ___ documents

A

permanent and legal

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4
Q

in case of malpractice what forms prevent the dentist from being convicted

A

all forms present in chart

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5
Q

dental records are used in ___ sciences

A

forensic

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6
Q

how long are adult patient records kept before being destroyed

A

10 years from date of last visit

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7
Q

how long are minor patient records kept before being destroyed?

A

10 years from the date of patient turning 18

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8
Q

what is quality assurance

A

program in place to monitor and evaluate treatments occurring in offices etc, to ensure standards of quality are being met

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9
Q

Dental records are a form of

A

risk management

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10
Q

PHI

A

personal health information

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11
Q

PIPA

A

personal information protection act

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12
Q

Pipa is a ____ legislation

A

provincial

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13
Q

When has provincial legislation been effective since?

A

2004

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14
Q

PIPA governs the collection, use and disclosure of

A

personal information by organization in respect to rights of individuals and needs of organization

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15
Q

HIPAA

A

health insurance portability and accountability act

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16
Q

PIPEDA

A

personal information protection and electronic documents act

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17
Q

Pipeda is a ____ legislation

A

federal

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18
Q

Federal legislation has been in place since

A

2000

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19
Q

when is federal legislation in effect

A

when submitting patient info across provincial borders

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20
Q

PIPEDA is for

A

establishing rules governing collection, use and disclosure of personal info recognizing right to privacy

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21
Q

A patient chart is composed of

A

registration, consent, medical history, dental history, treatment plan, and treatment record forms

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22
Q

where are medical alert stickers placed in the chart

A

inside the chart to protect patient confidentiality

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23
Q

when are registration forms filled out

A

prior to first treatment at/prior to first visit

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24
Q

the form pertaining to a certain treatment is the

A

consent form

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25
Q

when are medical/dental update forms completed

A

after each visit

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26
Q

implied consent is

A

the patients actions dictate their consent

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27
Q

written consent is

A

the patient signs a document outlining treatment

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28
Q

informed consent is

A

the patient agrees after knowing all info regarding treatment

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29
Q

a patient refusal of treatment must be

A

signed and dated by patient, and doctor

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30
Q

which form is the most detailed in the chart

A

clinical examination form

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31
Q

what is a level 1 (emergency) treatment plan

A

takes care of immediate problems (knocked out tooth) mostly pain management though

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32
Q

what is a level 2 (standard) treatment plan

A

restores dentition back to “normal function” (restorations)

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33
Q

what is a level 3 (optimum) treatment plan

A

restores dentition to max. function (veneers, crowns, bridges)

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34
Q

progress notes are aka

A

treatment record

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35
Q

progress notes are written in chronological order and detail

A

date, tooth #, treatment completed, communication between patient

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36
Q

records are owned by who

A

the dentist and they can’t be removed from the office

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37
Q

how do you correct a mistake on a chart

A

with a single strike through mistake with date and initials next to it

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38
Q

chief complaint

A

the purpose of visit

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39
Q

data must be

A

written in blue/black ink, signed and dated, chronological order

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40
Q

BP

A

blood pressure

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41
Q

CC

A

chief complaint

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42
Q

CUD

A

complete upper denturee

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43
Q

CLD

A

complete lower denture

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44
Q

PUD

A

partial upper denture

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45
Q

PLD

A

partial lower denture

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46
Q

Abr

A

Abrasion

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47
Q

Acr

A

acrylic

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48
Q

Porc

A

Porcalin

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49
Q

Ven

A

Veneer

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50
Q

Ag

A

amalgam

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51
Q

comp

A

composite resin

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52
Q

Ant, Post

A

Anterior and posterior

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53
Q

Tx

A

treatment

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54
Q

Pt

A

patient

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55
Q

Attr

A

attrition

56
Q

Ero

A

erosion

57
Q

PMH

A

past medical history

58
Q

PDH

A

Previous dental history

59
Q

HPC

A

history of present condition

60
Q

RCT

A

root canal treatment

61
Q

abutment is the

A

tooth/root/ implant used as retention for a fixed or removable prosthesis

62
Q

Diastema is the

A

abnormal open space between teeth

63
Q

Hypoplasia

A

the undergrowth or abnormal development of tissue

64
Q

Hyperplasia

A

overgrowth of tissue

65
Q

Pontic

A

the artificial tooth replacing a natural tooth

66
Q

mobility is

A

movement of a tooth in its socket

67
Q

periodontal pockets are created when the

A

depth of sulcus exceeds 3mm

68
Q

a restoration is AKA

A

a filling of amalgam or composite

69
Q

a geometric odontogram is when

A

the structure of tooth is represented by a circle

70
Q

a anatomic odontogram is when

A

structure of tooth is an accurate representation

71
Q

what is a mirror used for

A

indirect vision and light reflection

72
Q

an explorer is used for

A

detecting imperfections in enamel and restorations

73
Q

probes are for

A

measuring depth of sulcus

74
Q

radiography is used to identify

A

decay, defective restorations, pathology, periodontal condition, and developmental conditions

75
Q

intra oral imaging is

A

a small camera used to display image/video of mouth on a screen for patient reassurance

76
Q

intraoral/extraoral photography is

A

orthodox before and after shots

77
Q

a palpation (extra oral) exam is

A

using fingers to feel texture/size of tmj,facial muscles, lymph nodes

78
Q

types of patients

A

new, emergency, consulting, recall

79
Q

a recall appointment is with the

A

hygienist

80
Q

when palpating your looking for

A

shape, size,texture abnormalities

81
Q

Class I cavitys

A

occlusal pits+fissures of posterior teeth
Buccal lingual pits molars
Lingual pits anterior maxillary teeth

82
Q

Class II cavitys

A

mesial distal pits on molars

83
Q

Class III cavitys

A

Mesial distal anterior teeth

84
Q

Class IV cavitys

A

Mesial distal incisal anterior teeth

85
Q

Class V Cavity

A

Cervical third of any tooth

86
Q

Class IV Cavity

A

cusp tips, incisal edges

87
Q

Amalgam is charted as

A

completely shaded in of connected surfaces in red or blue

88
Q

Composite is charted as

A

Outline of connected surfaces in red or blue

89
Q

Recurrent decay is charted

A

by outlining existing blue restoration with red

90
Q

A red right angle triangle is known as

A

overhang, long side on affected tooth

91
Q

Sealants are charted as

A

an S on occlusal surface, red or blue

92
Q

A red circle at the apex of a root is a

A

abscess

93
Q

How do you chart a root canal

A

by drawing a line down the root(s) in red or blue

94
Q

Post and cores are charted as

A

line through centre of tooth with arrow on crown side in red or blue

95
Q

Circling the cervical third and writing ABR in red is how to chart what

A

abrasion

96
Q

To chart attrition you

A

draw a horizontal line on incisal/occlusal edge and write attr in red

97
Q

A circle on the top of the tooth in red with Ero written is

A

erosion

98
Q

Recession is charted by

A

drawing a line below gingival margin and writing amount receded in red

99
Q

Furcation is charted how

A

by drawing symbol depending on class between roots in red

100
Q

M1,M2, or M3 written in red would be

A

mobility

101
Q

how would you chart over/under eruption

A

an arrow signifying over or under with amount above tooth in red

102
Q

a semicircle arrow above a tooth is for

A

medial or distal rotation

103
Q

drifting is charted as a

A

arrow pointing medial or distal above the tooth in red

104
Q

pulp written above a tooth in red or blue is a

A

pulpotomy, only on primary teeth

105
Q

a space maintainer is drawn as a

A

crown on adjacent tooth with bar the stretches across missing tooth in red or blue

106
Q

an endentulous arch is a

A

blue X across affected arch

107
Q

how would you chart a partially erupted tooth

A

circle all of tooth except half of crown and write PE in red

108
Q

A fully red circled tooth indicates a

A

impacted tooth

109
Q

A extraction is charted as a

A

single diagonal red line through tooth

110
Q

a blue X through tooth indicates a

A

missing tooth

111
Q

Crowns are charted by

A

outlining all surfaces of tooth (material dependant) in red or blue and writing material

112
Q

PJC

A

porcelain jacket crown

113
Q

PFM

A

porcelain fused to metal crown

114
Q

Stainless steel crowns are charted as

A

outline all surfaces and write SS on occlusal in red or blue, mainly primary teeth after root canal

115
Q

A only buccal, facial outline with Ven written in blue or red is a

A

Veneer

116
Q

How would you chart a bridge

A

X through missing tooth, draw type of crown, connect with =, write material/type of bridge in red or blue

117
Q

A Maryland bridge would be charted as

A

a fake tooth with wings cemented to linguals of adjacent teeth in red or blue

118
Q

a 3 tooth cap over a missing tooth and 2 shaved down teeth is a

A

fixed bridge

119
Q

what is the difference between and inlay and an onlay

A

inlays don’t have any cusps included

120
Q

Inlay would be charted as

A

gold or porcelain, drawn as MOD in red or blue with material written above

121
Q

an onlay is charted as

A

gold or porcelain, drawn as modb in red or blue with material written above

122
Q

2 red vertical lines between teeth is known as

A

diastema

123
Q

a red zigzag is a

A

fracture

124
Q

how would you chart a CUD and CLD

A

line drawn below arch with lines attaching that extend through each tooth, in red or blue, write CUD or CLD

125
Q

how would you chart a PUD and PLD

A

line drawn below arch connecting with lines extending though the missing teeth, write PUD or PLD in red or blue

126
Q

blue or red horizontal lines through a root signifies a

A

implant

127
Q

A fixed lingual retainer is drawn as

A

a line on lingual anterior teeth with dots on each end in red or blue

128
Q

Periodontal probing is done to

A

measure how much epithelial attachment has been lost to disease

129
Q

a probe measurement of 0-3mm is considered

A

healthy, recorded in blue or black ink

130
Q

A probe measurement of 4mm or more is considered

A

diseased, recorded in red ink

131
Q

how many probing measurements per tooth

A

6

132
Q

Which readings are completed first when doing full dentition probe

A

facial/buccal readings

133
Q

how is the dentition divided for periodontal probing

A

into sextants

134
Q

the bleeding index is

A

how much bleeding is observed during probing

135
Q

how is bleeding recorded on a periodontal chart

A

with a red * above the measurement

dental assisting mda (35 decks)

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