Documentation, EOE, IOE, findings and occlusion Flashcards
Patient records include (5)
- patient assessment
- diagnosis
- care plan
- consent
- treatment implemented
what is the purpose of each chart
dental chart - existing conditions of the actual teeth, restorations, caries, missing teeth, sealants, prostheses, attrition, wear facets
periodontal chart - clinical features of the periodontium, gingiva, probe depth, ging. margin, bleeding, mobility
updated routinely for changes
what are the forms of charts
anatomic (complete drawings of the teeth, we use this)
geometric (provides space to record for each tooth)
what is the sequence of charting? (5)
- basic entries: name, birthday, address, etc.
- systematic procedure: have a set routine, whole mouth rather than of one tooth
- radiographic charting: missing, unerupted, impacted teeth, deviations from normal seen on radiographs
- supplemental observations: observations made during clinical exam, EX caries seen on radiograph should be further evaluated during exam
- study models: useful for occlusion records
universal tooth numbers
- 1-32
- A-J
international tooth numbers
- quadrants 1-4
- tooth 1-8 from central incisor out to molar
- primary quadrants 5-8
- teeth 1-5 from central incisor out to molar
Palmer system numbers
- 1-8 from central incisor to molar
- upper case letters A-E
- draw the inverted box
whats in the progress note/ services rendered note
chronological history of treatment received by the patient during each appointment
- purpose of visit
- history review
- assessment findings
- description of treatment provided
- drugs used or prescribed
- oral self care and given care
- referrals/ consultations
- lab tests ordered and results
- next visits, scheduled or recommended, or cancelled
- objective report of patient conversations on phone/email
- signature of clinician and date
(S) ubjective examples
age gender
treatment planned
medical history
medications and allergies
chief complaint
self care regimen
social history
(O) bjective examples
- vital signs
- head and neck findings
- periodontal findings
- hard tissue findings
- radiographic findings
- comparison of current vs previous findings
(A) ssessment examples
- risk factors
- disease risk level
- biofilm/calculus level
- periodontal diagnosis
(P) lanning examples
- treatment provided
- medications/local anesthesia used
- Consult w other providers
- self care instructions
- goals for improvement
- pending/planned dental interventions
when was hippa created and when did it start being used in dental setting
1996
April 14, 2003
what is the hippa privacy and security rules
privacy: Establishes a national standard to protect individual’s privacy and access to medical records and other health information
security: updated in 2013 for digital; national set of security standards for protecting health
information that is held or transferred in electronic form
healthcare FACILITIES are responsible to (7)
◦ Develop required privacy and confidentiality forms
◦ Adopt written privacy policies and educate staff about confidentiality of patient
information
◦ Appoint staff privacy officers and privacy contact persons
◦ Provide patients with a Notice of Privacy Practices document at the beginning
of their care and receive a signed acknowledgment of receipt
◦ Implement security measures, policies, and formal protocols that protect
patient information
◦ Conduct analysis of security risks and vulnerabilities.
◦ Establish sanctions for workforce members who fail to comply with policies
healthcare PROVIDERS are responsible to (1)
Comply with protocols and practices that protect patient information and
avoid inappropriate disclosure
patients have the right to (6)
◦ Receive a copy of personal health records
◦ Ask to change incorrect or incomplete information
◦ Receive reports on when, why, and with whom their health information is shared
◦ Decide, in some cases (such as marketing), whether health information can be shared
◦ Ask to be contacted regarding health information in a specific location or by a specific
method such as telephone, e-mail, or mail
◦ File a complaint with the provider, health insurer, or United States government
regarding concerns about use of their health information
what are the 3 separate standards for the HIPPA security rule
◦ Administrative safeguards: limitation of access to appropriate members in the workforce
◦ Physical safeguards: use of storage systems and procedures that prevent access for
unauthorized individuals
◦ Technical safeguards: use of technology, such as coding and encryption, to control
access to patient information
what may be the first indicator of subclinical disease processes
changes in oral tissues
what is prognosis? and the 5 year survival rate for oral and pharyngeal cancer
the likely outcome for a specific cancer; it’s highly variable and depends on the stage/size of the lesion/whether it has spread/and location
Early detection is KEY to survival
The 5-year survival rate for oral and pharyngeal cancer is 68%
what are the risk factors for oral cancer (5)
- Age - Incidence peaks in persons 55
to 74 years - Gender - Men are 2x more likely
than women to develop it - Sunlight - Exposure is a risk factor
for lip cancer - Tobacco and Alcohol Use - either one increases risk; use in combination poses an even higher risk
- Human Papillomavirus (HPV)
what are the most common sites for oral cancer
- Oropharnyx (11%)
- Floor of the mouth (14%)
- Lateral border of tongue (30%)
- Lower lip (38%)
what is bimanual palpation
Using finger of one hand and fingers of
other hand simultaneously to move or
compress tissue, holding the fingers
closely together to avoid missing areas
what is circular palpation used for
to palpate suspected lesions for more information
what are the parts of the EOE in order (6)
- Overall appraisal of head, neck, face,
and skin - Lymph nodes of head and neck
- Salivary and thyroid glands
- Temporomandibular joint (TMJ)
- Muscles and sinuses
- Mallampati score
what should you look for the in overall appraisal of head and neck (7)
*Seat client in upright position
* Good lighting
* Exposure of area being assessed-remove any neck-related clothing, glasses, denture, or appliances
* Perform an overall evaluation of the head, neck, eyes, face, lips and surrounding skin
* Face: expression; evidence of fear or apprehension-twitching, paralysis, signs of abuse
* Skin: color, texture, blemishes, traumatic lesions, eruptions, swellings, growth
* Eyes: size of pupils, color of sclera, eyeglasses, protruding eyeballs
lymph nodes (3)
- grouped in clusters, connecting
lymphatic vessels, filter toxic products from the
lymph to prevent entry into the blood - Healthy: Cannot be visualized or palpated. No tenderness to palpation.
- Can be superficial or deep in the tissue
difference and similarities between infected and malignant lymph nodes
Infected lymph nodes
* Tender
* Bilateral swelling (on both sides of head or neck)
* Freely movable from underlying structures
Malignant Lymph Nodes
* Not tender
* Matted (stuck to each other)
* Fixed (stuck to underlying tissue)
* Unilateral (enlarged on only one side of the head or neck)
Both
* Palpable and Firm
* Undergone lymphadenopathy/enlargement
* May indicate disease process is active
* Document if found!
palpation technique for occipital lymph nodes
bilateral circular palpation
palpation technique for posterior and pre-auricular lymph nodes
manual circular palpations
submental lymph nodes palpation technique
bi-digital palpation
