Diagnostic Record Chapter 26&27 Flashcards
1
Q
patient dental records must be
A
accurate, legible, organized and accessible
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
3
Q
dental records are ____ and ___ documents
A
permanent and legal
4
Q
in case of malpractice what forms prevent the dentist from being convicted
A
all forms present in chart
5
Q
dental records are used in ___ sciences
A
forensic
6
Q
how long are adult patient records kept before being destroyed
A
10 years from date of last visit
7
Q
how long are minor patient records kept before being destroyed?
A
10 years from the date of patient turning 18
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
9
Q
Dental records are a form of
A
risk management
10
Q
PHI
A
personal health information
11
Q
PIPA
A
personal information protection act
12
Q
Pipa is a ____ legislation
A
provincial
13
Q
When has provincial legislation been effective since?
A
2004
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
15
Q
HIPAA
A
health insurance portability and accountability act
16
Q
PIPEDA
A
personal information protection and electronic documents act
17
Q
Pipeda is a ____ legislation
A
federal
18
Q
Federal legislation has been in place since
A
2000
19
Q
when is federal legislation in effect
A
when submitting patient info across provincial borders
20
Q
PIPEDA is for
A
establishing rules governing collection, use and disclosure of personal info recognizing right to privacy
21
Q
A patient chart is composed of
A
registration, consent, medical history, dental history, treatment plan, and treatment record forms
22
Q
where are medical alert stickers placed in the chart
A
inside the chart to protect patient confidentiality
23
Q
when are registration forms filled out
A
prior to first treatment at/prior to first visit
24
Q
the form pertaining to a certain treatment is the
A
consent form
25
when are medical/dental update forms completed
after each visit
26
implied consent is
the patients actions dictate their consent
27
written consent is
the patient signs a document outlining treatment
28
informed consent is
the patient agrees after knowing all info regarding treatment
29
a patient refusal of treatment must be
signed and dated by patient, and doctor
30
which form is the most detailed in the chart
clinical examination form
31
what is a level 1 (emergency) treatment plan
takes care of immediate problems (knocked out tooth) mostly pain management though
32
what is a level 2 (standard) treatment plan
restores dentition back to "normal function" (restorations)
33
what is a level 3 (optimum) treatment plan
restores dentition to max. function (veneers, crowns, bridges)
34
progress notes are aka
treatment record
35
progress notes are written in chronological order and detail
date, tooth #, treatment completed, communication between patient
36
records are owned by who
the dentist and they can't be removed from the office
37
how do you correct a mistake on a chart
with a single strike through mistake with date and initials next to it
38
chief complaint
the purpose of visit
39
data must be
written in blue/black ink, signed and dated, chronological order
40
BP
blood pressure
41
CC
chief complaint
42
CUD
complete upper denturee
43
CLD
complete lower denture
44
PUD
partial upper denture
45
PLD
partial lower denture
46
Abr
Abrasion
47
Acr
acrylic
48
Porc
Porcalin
49
Ven
Veneer
50
Ag
amalgam
51
comp
composite resin
52
Ant, Post
Anterior and posterior
53
Tx
treatment
54
Pt
patient
55
Attr
attrition
56
Ero
erosion
57
PMH
past medical history
58
PDH
Previous dental history
59
HPC
history of present condition
60
RCT
root canal treatment
61
abutment is the
tooth/root/ implant used as retention for a fixed or removable prosthesis
62
Diastema is the
abnormal open space between teeth
63
Hypoplasia
the undergrowth or abnormal development of tissue
64
Hyperplasia
overgrowth of tissue
65
Pontic
the artificial tooth replacing a natural tooth
66
mobility is
movement of a tooth in its socket
67
periodontal pockets are created when the
depth of sulcus exceeds 3mm
68
a restoration is AKA
a filling of amalgam or composite
69
a geometric odontogram is when
the structure of tooth is represented by a circle
70
a anatomic odontogram is when
structure of tooth is an accurate representation
71
what is a mirror used for
indirect vision and light reflection
72
an explorer is used for
detecting imperfections in enamel and restorations
73
probes are for
measuring depth of sulcus
74
radiography is used to identify
decay, defective restorations, pathology, periodontal condition, and developmental conditions
75
intra oral imaging is
a small camera used to display image/video of mouth on a screen for patient reassurance
76
intraoral/extraoral photography is
orthodox before and after shots
77
a palpation (extra oral) exam is
using fingers to feel texture/size of tmj,facial muscles, lymph nodes
78
types of patients
new, emergency, consulting, recall
79
a recall appointment is with the
hygienist
80
when palpating your looking for
shape, size,texture abnormalities
81
Class I cavitys
occlusal pits+fissures of posterior teeth
Buccal lingual pits molars
Lingual pits anterior maxillary teeth
82
Class II cavitys
mesial distal pits on molars
83
Class III cavitys
Mesial distal anterior teeth
84
Class IV cavitys
Mesial distal incisal anterior teeth
85
Class V Cavity
Cervical third of any tooth
86
Class IV Cavity
cusp tips, incisal edges
87
Amalgam is charted as
completely shaded in of connected surfaces in red or blue
88
Composite is charted as
Outline of connected surfaces in red or blue
89
Recurrent decay is charted
by outlining existing blue restoration with red
90
A red right angle triangle is known as
overhang, long side on affected tooth
91
Sealants are charted as
an S on occlusal surface, red or blue
92
A red circle at the apex of a root is a
abscess
93
How do you chart a root canal
by drawing a line down the root(s) in red or blue
94
Post and cores are charted as
line through centre of tooth with arrow on crown side in red or blue
95
Circling the cervical third and writing ABR in red is how to chart what
abrasion
96
To chart attrition you
draw a horizontal line on incisal/occlusal edge and write attr in red
97
A circle on the top of the tooth in red with Ero written is
erosion
98
Recession is charted by
drawing a line below gingival margin and writing amount receded in red
99
Furcation is charted how
by drawing symbol depending on class between roots in red
100
M1,M2, or M3 written in red would be
mobility
101
how would you chart over/under eruption
an arrow signifying over or under with amount above tooth in red
102
a semicircle arrow above a tooth is for
medial or distal rotation
103
drifting is charted as a
arrow pointing medial or distal above the tooth in red
104
pulp written above a tooth in red or blue is a
pulpotomy, only on primary teeth
105
a space maintainer is drawn as a
crown on adjacent tooth with bar the stretches across missing tooth in red or blue
106
an endentulous arch is a
blue X across affected arch
107
how would you chart a partially erupted tooth
circle all of tooth except half of crown and write PE in red
108
A fully red circled tooth indicates a
impacted tooth
109
A extraction is charted as a
single diagonal red line through tooth
110
a blue X through tooth indicates a
missing tooth
111
Crowns are charted by
outlining all surfaces of tooth (material dependant) in red or blue and writing material
112
PJC
porcelain jacket crown
113
PFM
porcelain fused to metal crown
114
Stainless steel crowns are charted as
outline all surfaces and write SS on occlusal in red or blue, mainly primary teeth after root canal
115
A only buccal, facial outline with Ven written in blue or red is a
Veneer
116
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
117
A Maryland bridge would be charted as
a fake tooth with wings cemented to linguals of adjacent teeth in red or blue
118
a 3 tooth cap over a missing tooth and 2 shaved down teeth is a
fixed bridge
119
what is the difference between and inlay and an onlay
inlays don't have any cusps included
120
Inlay would be charted as
gold or porcelain, drawn as MOD in red or blue with material written above
121
an onlay is charted as
gold or porcelain, drawn as modb in red or blue with material written above
122
2 red vertical lines between teeth is known as
diastema
123
a red zigzag is a
fracture
124
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
125
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
126
blue or red horizontal lines through a root signifies a
implant
127
A fixed lingual retainer is drawn as
a line on lingual anterior teeth with dots on each end in red or blue
128
Periodontal probing is done to
measure how much epithelial attachment has been lost to disease
129
a probe measurement of 0-3mm is considered
healthy, recorded in blue or black ink
130
A probe measurement of 4mm or more is considered
diseased, recorded in red ink
131
how many probing measurements per tooth
6
132
Which readings are completed first when doing full dentition probe
facial/buccal readings
133
how is the dentition divided for periodontal probing
into sextants
134
the bleeding index is
how much bleeding is observed during probing
135
how is bleeding recorded on a periodontal chart
with a red * above the measurement
