Documentation Flashcards
You should have complete and accurate documentation of:
-Patient assessment
-diagnosis
-care plan
-consent
-treatment implementation
Purpose of documentation:
-Means of communication between the members of the health team, as well as with their patients
-Facilitates coordinated planning and continuity of care
-Serve as a basis for evaluation of the quality of care (or standard of care)
-Data from health records are utilized in research and education
-Defense in malpractice claims
-Evidence for forensic situation (Disaster victim identification)
Good documentation in a pt record is:
-Able to be read and understood by a third party
-Avoid abbreviations unless a list is maintained by the practice
-Accurate and comprehensive
-Legible
-Objective
Proper pt record entries are:
-recorded promptly during or following treatment
-Recorded using clear and concise statements
-Dated
-Signed by the clinician
Components of a Patient Record:
-All information collected during initial examination and during continued care appointments is an official part of the permanent records
-All components of the dental hygiene process of care are addressed
-Required components:
- Signed acknowledgment of confidentiality measures
- Medical history and vital signs
- Dental history
- Clinical assessment and diagnosis
- Radiographic assessment
- Treatment recommendations and written treatment plan
- Informed consent
- Services rendered note for each patient visit
Components of a Patient Record (additional)
Additional components, required when applicable, include:
- Radiographs
- Caries risk assessment
- Anesthesia records
- Study models
- Oral photographs
- Orthodontic records, if available
- Laboratory orders and test results
- Referral records and copies of consultation correspondence with dental specialists or medical practitioners
Handwritten Record s
- Handwritten records are recorded legibly and written in ink
- Mistakes are corrected by placing a single line through the error, writing the correct information immediately after, and signing the entry
- If a late entry is necessary, the new information:
- Follows the most recent entry in the patient record
- Is noted as a late entry with a cross-reference to the original chart entry
- Includes the date and time that the late entry was made
- Strict infection control protocols are required to prevent contamination of paper records during patient care (can’t sterilize paper)
- For written records, a filing system is needed that provides accessibility to the health records by authorized personnel only.
Benefits of Electronic Health Record (EHR)
-Legible record of patient care accessible in real time
-Standardized format that is customizable
-Information sharing between providers to eliminate duplication of care
-Allow public health entities to gather data
-Enhance communication with consulting dental specialists, medical providers, or other multidisciplinary team members who may not be together at one clinical site
-Maintain digital radiographs and photographs within the patient record
Challenges of EHR
-Computer skills required.
-Technical support needed when problems arise so patient care is not interrupted.
-Computerized records require computer terminals where only authorized personnel can access required information.
-Computer monitors are directed away from the view of unauthorized persons.
-Infection control protocols include providing plastic barriers for computer keyboard and mouse.
Charting Purpose
-Dental chart (hard tissue): diagrammatic representation of existing conditions of the teeth
-Examples: Restorations, Caries
-Periodontal chart: indicates clinical features of the periodontium
Dental and periodontal charts are updated routinely to record changes in the patient’s oral features
-Symbols, drawings, and labels used need to be accurate representations of the oral condition
- In EHR, charting symbols are standardized
the purpose of each type of charting is defined by its
title
Charting purpose within the process of care
-Care planning: The charting is a graphic representation of the existing condition of the patient’s teeth and periodontium from which needed treatment procedures can be organized into a treatment plan
-Treatment: During dental and dental hygiene appointments, the charting is useful for guiding specific procedures
-Evaluation: The outcome and degree of treatment effects are determined by comparing the findings of the initially recorded examination with periodic follow-up examinations
-Protection: In the event of misunderstanding by a patient, or if legal questions should arise, the records and chartings are evidence
-Identification: In the event of emergency, accident, or disaster, a patient may be identified by the teeth for which a record has been maintained.
T/F- there are many variations of chart forms
true
Sequence of charting-
-Basic entries
-Systematic Procedure
-Radiographic Charting
-supplemental observations
-Study Models
Sequence of charting- Basic entries
-Name, birth date, address, phone number, emergency contact
-Date of appointment: Every entry is dated
Sequence of charting- systematic procedure
-A set routine is essential for complete and accurate charting
-Charting all of one item for the entire mouth, rather than complete chartings of one tooth, helps to ensure accuracy
Sequence of charting- radiographic charting
-Without presence of the patient (in private practice, not at ODU):
-Missing, unerupted, impacted teeth
-Endodontic treatment
-Overhanging margins of existing restorations
-Suspected caries
-Radiographic bone loss
-Other deviation from normal evident from the radiographs.
Documenting Extraoral and Intraoral Examination
-Specific objective: recognition of any deviations from normal that may be signs and symptoms of disease
-Occlusion
-Include amount and distribution of deposits (Calculus, Stain and Biofilm or other soft deposits)
