Emergencies & Records - Charting - Outcome 6

Question 1

The two types of charts are:

Answer 1

1. Tooth Diagrams - provides documentation that represents conditions of the teeth
2. Periodontal Charts - represents clinical features of the periodontum

Question 2

Tooth Diagrams

Answer 2

Two types of Tooth Diagrams :

Geometric - do not look like teeth, are made up a series of circles divided to represent the surfaces of the teeth

Anatomic - have drawings that look like teeth

Question 3

Anatomic Charts

Answer 3

have representative drawings that look like the surfaces of the teeth. These vary in the amount of tooth surfaces represented:

1. Some indicate only crowns of the teeth
2. Some indicates the crowns and a little of the roots
3. Some indicate the crowns and all of the roots

Question 4

Periodontal Chart

Answer 4

the periodontal chart is adapted to include more extensive information regarding the clinical features of the periodontium

Question 5

Tooth Positions - on chart

Answer 5

Although tooth relationships may look different when the arches are straightened out, they remain the same. The upper row of the diagram represents the maxillary teeth while the lower row represents the mandibular teeth. The teeth in the center of the chart represent the anterior teeth and those at each end represent the posterior teeth.

We are looking directly at the arch so the teeth on the right hand side of the chart represent the upper and lower left quadrants while those on the left, represent the upper and lower right quadrants.

Question 6

Occlusal Surfaces and Incisal Edges - on chart

Answer 6

When you look at the chart, you will notice that the “picture” of each of the posterior teeth is made up of three parts, while those of the anterior teeth are composed of only two parts.

The middle row of the posterior teeth represents the OCCLUSAL SURFACE of the posterior teeth.

The INCISAL EDGE of the anterior teeth is represented by the edges of the labial and lingual surfaces as they come together – indicated in the diagram below with a black line.

Question 7

Buccal and Facial Surfaces - on chart

Answer 7

The buccal and facial surfaces of the teeth are represented by the outer rows of the chart.

Question 8

Lingual Surfaces - on chart

Answer 8

The lingual surfaces of the teeth are represented on the inner rows of the chart.

Question 9

Mesial and Distal Surfaces - on chart

Answer 9

On the anatomical diagram, the entire mesial and distal surfaces are not actually shown. Instead, they are indicated along the mesial and distal edges of the other surfaces.

Question 10

Primary Dentition Charts

Answer 10

These Permanent Teeth guidelines apply to the primary dentition also, with ONE exception. Some primary chart shows only the buccal and occlusal surface of the primary molars and the labial and lingual surfaces for the anterior dentition.

Question 11

General Guidelines for Clinical Recording (Analog chart)

Answer 11

-A coloured pen is used to record dental/periodontal conditions on the dental chart.
-Black or blue symbols represent dental work that has been completed. This can indicate dental work completed by another dentist or work completed form previous appointments with the current dentist
-Treatment to be performed or conditions that require attention are recorded in Red, including periodontal recordings that require attention. (pockets that measure 4 and up).
-Charting should be recorded so outlines are neat and easy-to-read.
-Restorations should be charted exactly as they appear in the patient’s mouth.
-Accuracy is essential. A mistake could cause incorrect treatment to be done, or possible legal liability.

Question 12

Charting Symbols

Answer 12

The charting or recording of oral conditions is a form of dental shorthand. A variety of symbols and abbreviations are used to indicate conditions that exist on the teeth and supporting structures. The use of symbols makes it easy to look at a dental chart and identify conditions that exist without having to read a detailed narrative. No particular system is right or wrong but charting symbols need to be identified and used consistently by all staff members within a dental office.

Question 13

Mixed Dentition Charting

Answer 13

Both primary and secondary charts are required to rotate eruption patterns and dental conditions.

Question 14

Charting Teeth Present/Not Present in the Oral Cavity

Answer 14

When observing the patient’s dentition, the first step should be to count and identify the teeth present in the mouth. Your knowledge of eruption sequence and schedule, the anatomical landmarks of teeth, as well as their place in the arch, will help you make this determination.

Question 15

Charting OCCLUSAL Carious Lesions

Answer 15

Definition: A carious lesion does not stretch to the proximal sides of a tooth.

Notation: Outline the approximate size and shape of the carious lesion.

Note: If there are two occlusal pit lesions then record two separate occlusal lesions.

Question 16

Charting Carious Lesions - 2+ surfaces of posterior teeth

Answer 16

Definition: A carious lesion involving the 2+ surfaces will almost always involve the occlusal surface. These carious lesions will be restored as a single unit restoration but recorded/charged depending on the # of surfaces restored.

Notation: Outline the affected areas to the approximate size and shape of the carious lesion. This will likely involve 2+ surfaces.

How to read and write these lesions:

-Mesial “M” is always first
-Distal “D” is first when mesial is not involved
-Occlusal “O” and Incisal “I” are:
First only if the mesial or distal are not involved.
Second if mesial and distal are involved.
-Facial “F” or buccal “B” is first when it stands alone but always follows M, O, I, or D
-Lingual “L” is always last

Question 17

Charting Carious Lesions - Proximal on Anterior Teeth

Answer 17

Black’s Classification of Cavities:

Class 3 - interproximal surfaces
Class 4 - interproximal surfaces involving incisal surfaces

Outline the affected areas to the approximate size and shape of the carious lesions. This may include only one or both the lingual and facial surfaces.

Question 18

Charting Carious Lesions - Facial/Buccal & Lingual

Answer 18

According to the Black’s Classification of Cavities:
Class 1: buccal/lingual pit(s)
Class 5: gingival margin

Outline the affected areas to the approximate size and shape of the carious lesion.

Question 19

Charting Carious Lesions - Questionable Lesions

Answer 19

Suspected carious lesions require radiographs for confirmation.

-Outline the suspicious area with a dotted red line and write a red question mark beside the tooth.
-If the suspicious area is checked again – at a later date – outline the appropriate area with a dotted red line and mark “watch” beside the tooth. Some dental offices will date these notations too.

Question 20

What does Periodontal Charting include?

Answer 20

Periodontal charting includes pocket readings, furcations, tooth mobility, exudate (pus), and gingival recession. The clinical findings of the periodontal exam are recorded in the periodontal chart.

Question 21

Pocketing Charting

Answer 21

Sulci are located, assessed, and measured with a probe. – Healthy measurements 1-3 are recorded in blue and measurements that score 4 or greater are charted in red

The pocket (or sulcus) is continuous around the entire tooth and the entire pocket (or sulcus) should be measured. Six measurements are taken; three buccal and three lingual. “Spot” probing at various random locations within the oral cavity is inadequate

Most periodontal charts (computerized or paper) make provision for a first, second, and third reading to compare results of treatment.

Question 22

Bleeding or Pus when probing - charting

Answer 22

Probing, bleeding points and suppuration points should be recorded. A red dot above the sulcular measurement would indicate bleeding and an encircled dot would indicate the presence of “pus”.

Question 23

Alternative to manual probing - automated system

Answer 23

An alternative to manual periodontal probing is the automated system. In this system, a probe used with constant pressure is connected to a reading device (such as a computer). As the operator probes around a tooth the probe automatically records, stores and prints the periodontal exam.

Question 24

Furcation Involvement

Answer 24

A furcation is an area between two or more roots. Furcation involvement is the exposure of a furcation as a result of periodontal bone destruction. It is classified into three general classes depending on the degree of furcation exposure:

Grade I - Early, beginning involvement
The probe can enter the furcation area and the anatomy of the roots on either side can be felt by moving the probe from side to side.

Grade II - Moderate involvement
Bone has been destroyed to an extent that permits the probe to enter the furcation area but not to pass through it.

Grade III - Severe involvement
The probe can be passed between the roots through the entire furcation.

Grade IV Same as Grade III, with the exposure resulting from gingival recession

Question 25

Furcation Charting

Answer 25

When recording furcation involvement, some dentists will indicate the classification while some will indicate only the presence of furcation involvement. Furcation involvement is noted by placing a red open triangle for grade I, a closed triangle for class II, or coloured in triangle class III between the tooth roots.

Question 26

Mobility Charting

Answer 26

Because of the nature and function of the periodontal ligament, teeth normally have slight mobility. Mobility can be considered abnormal when it exceeds normal.

The most widely accepted method used to assess mobility is the Miller index. The scale is N, 1,2,3 or I, II, III are frequently used.

N=normal

1=slight mobility, greater than normal

2=moderate mobility, greater than 1mm of displacement

3= severe mobility, tooth moves vertically and is depressible in the tooth socket

Mobility can be charted at the root of the tooth or there may be a specific line on the periodontal chart.

Question 27

Recession Charting

Answer 27

Recession is the exposure of the root surface which results from the apical migration of the junctional epithelium. Apparent, visible recession is evidenced by the position of the gingival margin. An area of root surface may be seen above the gingival margin.

Recession is recorded on the appropriate tooth surface (buccal, labial or lingual) with a curved red line following the shape of the cementoenamel junction. The amount or depth of the recession is measured with a probe and recorded in millimeters

Question 28

Abrasion charting

Answer 28

Abrasion is the mechanical wearing away of tooth substances by forces other than mastication. The most common cause is an abrasive dentifrice applied with vigorous horizontal tooth brushing. It appears as a wedge-shaped notch with a hard, smooth, shiny surface and clearly defined margins.

Most dentists chart abraded areas with double straight red lines across the appropriate tooth surface (buccal, labial, lingual) just below/above the cemento-enamel junction.

Question 29

Gingival Hyperplasia

Answer 29

Hyperplasia refers to an increase in the size of a tissue or organ caused by the increase in the number of cells in normal arrangement. Hyperplasia is recorded on the appropriate tooth surface (buccal, labial or lingual) with a curved red line following the shape of the gingiva.

Question 30

Components of a SAIT Dental Clinic Chart

Answer 30

The dental chart is a permanent record of a patient’s dental care. At SAIT dental charts may include the following documents.

They should be present in the following order:

1. Medical Dental History Questionnaire
   -Personal History
   -Medical History
   -Dental History
2. Medical Status Update/Dental History Status Update
3. The Consent and Waiver Form
4. Schedule A
5. Treatment Forms (with the most recent on top)
   -Clinical Observations (preventive, radiography, impressions, and sealants)
   -Anatomical Charting, Periodontal Charting, and Plaque Records
   -DA plan for treatment

Additional documents
-Sports guard and whitening tray requisitions
-Printed radiographs
-Other documents relating to the patient’s dental treatment

7. Clinical Notes
8. Referral Form
9. Sterilization monitoring form

Question 31

Recording Clinical Notes

Answer 31

1. All entries must be made in INK.
2. The information must be CORRECT …. CLEAR …. COMPLETE.
3. Handwriting must be neat and legible so that someone else can read it.
4. Entries must be made PROMPTLY. Usually, this is done before the patient leaves at the end of the visit.
5. To save time and space, commonly accepted abbreviations are used to describe the services performed.
6. The procedure is noted on the dental chart (odontogram) and then described in the clinical notes.
7. All entries should be initialed by the person who made the entry.
8. All entries must be dates. At SAIT this It is stated by DAY – MONTH – YEAR. SAIT uses two-digit numerical dates.
9. Abbreviations may be used with the exception of drug names and prescriptions - NEVER abbreviate the name of a drug administered; ALWAYS use the full name.

Question 32

PARTS Notes

Answer 32

This is a written, detailed description of each patient visit. Standardized daily chart entries are used to ensure consistent formatting and location of information which assists in providing quality patient care. Standardization of chart entries also allows for easy identification of completeness and accuracy of chart entries. PARTS Notes are used at SAIT to standardize the daily chart entries.

P = Problem and/or Procedure: what procedure/treatment are you planning on doing today?

A = Assessment: medical history update and notes about the patient’s health, including oral health.

R = Requisitions/Recommendations and/or Prescriptions: local anesthetics used, medications or N/A if not applicable

T = Treatment: document the procedures that were completed at the appointment
The tooth/teeth number
The tooth/teeth surface(s) involved
The procedure (ordered in the steps performed) including the:
Medicament(s) (name, area administered, and dosage)
Material(s) (name and how it was used)
Discussions that apply to treatment (i.e. medical updates and post-operative instructions.)
Any unusual circumstance or situation occurring during the procedure and any steps taken to resolve the problem.

S = Strategy: What is the plan following this appointment

Comments: This is where you put any information that does not fit into any of the above, but that you feel it is important to make note of.

Question 33

Purpose of a Chart Audit

Answer 33

A chart audit ensures that all documents involved in a patient’s dental care are:

Present and signed off by all parties to avoid litigation.
Complete to ensure that a patient is receiving quality care.
Organized in chronologic order to increase the efficiency of patient care and possible for accurate research purposes.

Question 34

Chart Audits and System Set-Ups for Active Files

Answer 34

An active file is a patient chart that exists because the patient has returned for dental treatment. At SAIT A patient is deemed to be an active patient if they have been to the SAIT Dental Clinic within the last two years. External and internal chart audits must be completed on these charts after every visit.

Question 35

External Chart Audit

Answer 35

An external chart audit refers to how a chart is prepared to be filed. When an external chart audit is to be completed, color markers are selected and placed in a specific location of a hanger.

Question 36

External Chart Marker Colours

Answer 36

Various Colours:
- each letter of the alphabet will be designated a color to correspond with the jirst letter of a patient’s last name.
- Hanger location: second slot from the left

Red:
- A medical alert exists
-Hanger location: 3 spaces to the right of the alphabet tab

Question 37

Internal Chart Audit

Answer 37

An internal chart audit refers to the completeness, quality, and organization of the information found inside a patient chart. The general guidelines are as follows:

Ensure that all documents are complete (date and signatures) and organized in the appropriate order (see “Components of a SAIT Dental Clinic Chart” in the previous objective for the order of documents).
A new health history form must be completed four years after the previous one was completed. Old services rendered forms and medical update forms will stay as part of the new active chart to maintain a chronological log of a patient’s treatment history.
Any patient who has not been seen in the last two years will be transferred from active to inactive and stored in a secure environment.

Question 38

Before a patient chart is filed ensure that:

Answer 38

-An external and internal chart audit has been completed.
-The chart is in good condition – with a solid hanger and sleeve
-Ensure that the chart assessment indicator is visible.

Question 39

Chart Audits and System Set-Up for Inactive Files

Answer 39

Ensure all records including x-rays and treatment plans are included in the archived files.
Patient charts will be archived (inactivated) after 2 years from the date of the last visit.
These files are moved into inactive storage areas without chart hangers.
Electronic patient files are to be flagged as non-active.
Dental records need to be securely stored for the appropriate length of time as determined and reasonable for business and legal purposes. In Alberta, patient records for adults must remain accessible for a minimum period of ten (10) years following the date of the last service, and patient records for minors must be accessible for a minimum period of ten (10) years past the patient’s age of majority. In the event of a patient becoming deceased, the retention period is not changed

Question 40

Chart Order

Answer 40

Medical/Dental History Questionnaire
Medical/Dental Update Form (reverse chronological order in the chart)
Consent
Schedule A

Preventive Procedures Forms:
Dent 262 Clinical Observations (pink)
Odontogram and biofilm control record (blue)
Dent 262 DA Plan for Treatment (Green)
Impression Clinical observations (pink)
Dental Radiography Clinical Observations (purple)

Services Rendered
Referral Form
Sterilization Form

White forms = Mandatory
Coloured forms = specific treatment

*Besides treatment forms, all other forms will be placed in chart with the most recent on top followed by the rest in reverse chronological order.

Question 41

Probing Codes

Answer 41

Code 0 - colour on probe completey visible, no calculus, no defective margins
Code 1 - colour on probe completey visible, with bleeding
Code 2 - colour on probe completey visible, with calculus
Code 3 - coloured probe partially visible
Code 4 - color on probe not visible

Question 42

Mobility Classes

Answer 42

N = Normal

Class I - moved 1mm in any direction
Class II - more than 1mm in any direction, NOT depressable into socket
Class III - moving buccolingually, depressable into socket

Question 43

Furcation Classes

Answer 43

Class I - furcation beginning, cannot enter with probe & cannot see on xray
Class II - can enter from one aspect
Class III - covered with soft tissue, complete involvement on both sides
Class IV - no soft tissues, complete involvement on both sides