diagnostic records

Question 1

what are components of the patient record

Answer 1

patients medical and dental history
clinical examinations
diagnosis
radiographs
rferral letters
drug prescriptions
lab prescriptions
treatment and prognosis

Question 2

what are legalities of the patient record

Answer 2

dental records are permanent documents of the dentist
a legal document
- can be used as evidence in a legal settlement or lawsuit
- reference tool in a forensic case
- reference for appropriate third parties like dental insurance
- patient should sign informed consent form

Question 3

where should the mdeical alert be placed within the patient record

Answer 3

if it is paper, it should be placed on the inside of folder to maintain confidentiality

should contain:
- premedication
- drug allergies
- latex allergy
- pregnancy

Question 4

what is proper recording of dental procedures

Answer 4

treatment plan
- plan of care should be recorded on treatment plan
- will be sequenced to address problems identified during examination

progress note
- will have details of what was accomplished
- date, tooth number, treatment and communication with patient

Question 5

what is quality assurance in the dental practice

Answer 5

• routine forms are completed for each patient
• timely recall of patients
• dental records are kept for each active patient
• when radiographs are taken
• current and up to date emergency protocols
• current and up to date licenses, registrations, certifications and training