Emergencies & Records - Outcome 1 Flashcards

1
Q

Freedom of Information and Protection of Privacy Act (FOIP) (Public - in Alberta) (October 1, 1995)

A

Protect personal information in the custody or control of public bodies such as:
Schools, Government agencies, health care bodies

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2
Q

Health Information Act (HIA) (Public or Private in Alberta) (April 25, 2001)

A

Protects health information of individuals in the custody or control of custodians in private or public sector
Covers custodians (doctors, dentists, hygienists)
Also covers affiliates (assistants, receptionists, etc.)

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3
Q

Personal Information Protection and Electronic Documents Act (PIPEDA) (Private - Federal) (January 1, 2001)

A

Sets national standard for privacy practices in the private sector
applies to every organization across Canada when collecting, using, or disclosing personal information while carrying out a commercial activity within a province unless a province passes legislation that is substantially similar to PIPEDA (based on the same purposes and rules). For Federally regulated - (banks, telephone companies) located in AB

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4
Q

Personal Information Privacy Act (PIPA) (Private - Alberta) (January 1, 2004)

A

Protects personal information in custody or control of a private sector organization (such as: Dental clinics, private schools, non-for-profit organizations)

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5
Q

Health Professions Act (HPA) (Public)

A

governs the practice of 32 regulated health professions, sets out standard processes for colleges for registration, continuing competence, complaints and discipline and establishes a board that advises the Minister

Under HPA, health professionals are governed by regulatory bodies called “colleges” in Alberta for us DA’s it is the CADA (College of Alberta Dental Assistants)

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6
Q

The Principles of HIA

A

The HIA applies to health information resulting from health services provided by a custodian.
It is a principle of the HIA that access to records be given unless the Act specifically allows the record to be withheld. This right of access is balanced by the need to protect individual privacy.
The HIA controls how health information is collected, used, and disclosed. It prevents another person from seeing an individual’s health information without their consent while enabling health information to be shared and accessed to provide health services and manage the health system.
Individuals can ask to see or have a copy of their health records if a custodian holds them.
Individuals have the right to request that their health information be corrected if it is not accurate. This is not an absolute right, and a request to correct information may be turned down.
The Act provides for review by the Information and Privacy Commissioner if individuals are not satisfied with the decisions of custodians in response to requests made under the Act. In cases where correction of health information has been refused, an individual may request a review of the decision by the Commissioner OR they may have a statement of disagreement attached to their health record.
Individuals can also complain to the Commissioner of the OIPC if they believe their health information has been collected, used, or disclosed in violation of the HIA (Alberta Queen’s Printer, 2022).

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7
Q

The Principles of FOIP

A

The FOIP Act legislates that applicants have the right to access records held by the government. It is a principle of the Act that access to records be given unless the Act expressly allows the record to be withheld. The right to access is balanced by the need to protect individual privacy.
The Act controls how personal information is collected, used, and disclosed. It prevents another person from seeing your personal information without consent.
Individuals can ask to see records held by the government, including personal information. Individuals have the right to request that personal information be corrected if it is not accurate.
The Act provides for review by the Information and Privacy Commissioner if individuals are not satisfied with the decisions of public bodies in response to requests made under the Act.
Individuals can also complain to the Commissioner of the OIPC if they believe their personal information has been collected, used, or disclosed in violation of the Act (Alberta Queen’s Printer, 2023).

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8
Q

Principles of PIPA

A

Personal information in the custody or control of private sector organizations as it relates to commercial transactions or activities will be subject to the Act.
Personal employee information will also be covered by PIPA.
PIPA will allow individuals to request access to their own personal information, including their personal employee information, and to request that personal information be corrected if the accuracy of the information is disputed.
Just as the Information and Privacy Commissioner may review decisions by organizations and agencies subject to the Freedom of Information and Protection of Privacy Act or the Health Information Act, PIPA also allows the Commissioner to review the decisions of private sector organizations to deny an individual access to their own personal information, or to refuse a request for correction to their own personal information.
Individuals may also make a complaint to the Commissioner if they believe their personal information has been collected, used, or disclosed without proper authority or without their consent (Alberta Queen’s Printer, 2022a).

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9
Q

The Personal Information Protection and Electronic Documents Act

A

The Personal Information Protection and Electronic Documents Act (PIPEDA), sets national standards for privacy practices in the private sector. Alberta and British Columbia have both passed similar laws, known in each province as the PIPA (Office of the Privacy Commissioner of Canada, [OIPC], 2004).
Both the federal Act, PIPEDA, and Alberta’s PIPA focus on protecting personal information in the private sector.
PIPEDA applies to every organization across Canada when collecting, using, or disclosing personal information while carrying out a commercial activity within a province unless a province passes legislation that is substantially similar to PIPEDA (based on the same purposes and rules).

Where health information is being transferred across provincial boundaries in relation to commercial activity, such as in the case of obtaining payment from an insurance company located outside of Alberta, the provisions of the federal Personal Information Protection and Electronic Documents Act (PIPEDA) may apply (CDSA, 2016a).

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10
Q

Privacy is..

A

Collecting, using, disclosing, and safeguarding, personal info

is the right of an individual to have some control over how his or her personal health information is collected, used, and/or disclosed and is governed by applicable privacy legislation, including Alberta’s Health Information Act (HIA) (Government of Alberta, 2021a).

Patients have a right to keep their health information private and control who can access it. Patients also have the right to:

Receive a copy of personal health records.
Ask to change incorrect or incomplete information.

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11
Q

Confidentiality is..

A

Keep info secret.
Do not tell anybody or else you lose trust.

is the obligation of a person or organization to protect the information entrusted to it (CDSA, 2016a). Discussion about a patient’s personal information, medical history, or treatment must be held in confidence and is not to be shared with anyone. This includes spouses, family, friends, or other dental healthcare professionals who are not directly involved in a patient’s care — to do so is a breach of patient confidentiality. You cannot reveal the identity of a patient or any other information from a patient’s record without the patient’s consent (Robinson, 2024). Breaches of confidentiality can result in a lawsuit against you as a dental assistant.

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12
Q

Autonomy

A

self-determination, - a persons choice to think, judge, and act independently without unwarranted influence

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13
Q

beneficence

A

doing good for others

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14
Q

code of ethics

A
  • Outlines the responsibility of the dental assistant to the patient to abide by all applicable legislation
    governing practice, privacy, confidentiality, and human rights (CADA, 2024a).
  • The Code of Ethics goes further to provide ethical statements meant to provide guidance to ensure that a patient’s privacy is maintained. It is unethical to disclose any personal information about a patient.
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15
Q

ethics

A

moral standards of conduct: rules or principles that govern proper conduct

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16
Q

justice

A

fair treatment of the patient

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17
Q

nonmaleficence

A

of no harm to the patient

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18
Q

veracity

A

truthfulness; not lying to the patient

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19
Q

CADA Code of Ethics

A

1.1 Generally

a) The health and well-being of the patient is the priority in all professional interactions.

b) Dental Assistants:

i. take professional responsibility for all professional actions;

ii. engage in best practices;

iii. competently apply knowledge and skills to avoid causing harm;

iv. if harm occurs, disclose the issue to the patient and supervisor as soon as practicable and take appropriate steps to minimize the harm; and,

v. evaluate processes to prevent recurrence.

c) Dental Assistants are knowledgeable of and practice to the current standard of care, seeking sound scientific information to support practice decisions. The current standard of care encompasses, but is not limited to, patient autonomy, current infection prevention and control procedures, occupational health and safety requirements and evidence-based use of appropriate procedures and materials.

d) Services are provided without bias or discrimination and communications are respectful and truthful.

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20
Q

What is health care information?

A

Diagnostic, treatment and care information,
including health service provider information; and
* Registration information, including a person’s personal health number

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21
Q

What is a “health service”?

A
  • The Health Information Act defines a “Health Service” as a service which provides any of the following to an individual:
    ◦ protecting, promoting, or maintaining physical and mental health;
    ◦ preventing illness;
    ◦ diagnosing and treating illness;
    ◦ rehabilitation; or
    ◦ caring for the health needs of the ill, disabled, injured or dying
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22
Q

General Principle of Privacy Laws

A

Right of access vs. right to privacy
* Control collection, use and disclosure
* The role of patient consent – when?
* A person must be allowed to view or obtain a copy of their records
◦ Note that this not have to happen at the moment of the request
◦ Dental offices have 30 day to comply

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23
Q

Collection & Use

A
  • You may only use the patient’s information for the purpose that it was provided at the time that you collected the information from the patient
    (Easton, 2020).
  • You may need consent from the patient to use their information.
    ◦ If you intend to use the patient’s information for a purpose that is different from the original purpose that
    the information was collected for, you most likely need to receive the patient’s consent to do this
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24
Q

Disclosure

A

The disclosure of information occurs when it is shared outside of the health information custodian that collected it (Easton, 2020).
* Disclosure also occurs when personal health information is shared for a reason that differs from the reason why the information was collected
(Easton, 2020).

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25
Q

HIA Information Managers

A

Information managers are authorized through
written agreement (Information Manager
Agreement [IMA]) by a custodian to use health information in the following ways:
◦ Process, store, retrieve or dispose information;
◦ Strip, encode or otherwise transform information; or,
◦ Provide information management or information technology services (Easton, 2020)

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26
Q

Privacy Officers

A

Each custodian must designate a Privacy Officer.
The Privacy Officer’s role is to:
◦ Monitor who can access health information.
◦ Identify privacy compliance issues.
◦ Ensure privacy and security policies and procedures are followed.
◦ Ensure staff and contractors are aware of their responsibilities and duties.
◦ Provide advice and interpretation of the Health Information Act and respond to requests for access to or correction of health information

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27
Q

Information & Privacy Commissioner

A
  • Privacy law experts – they are the authority if you are uncertain
  • They conduct and review investigations of
    breaches (and much more)
    ◦ Under the Health Information Act, it is mandatory to report a breach of privacy, no matter the circumstances, to the OIPC
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28
Q

Standards of Practice - CADA

A

CADA’s Standards of Practice state that dental assistants must understand the requirements of the Health Information Act and the custodian’s policies and procedures for protecting patient’s personal and health information
* Custodians are responsible for implementing security measures, policies, and protocols that affiliates must abide by.
* Revealing information about a patient is in
contravention of the HIA.

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29
Q

Confidentiality exceptions

A

There are legal requirements mandating that dental healthcare providers report cases of suspected child or elder abuse to protect those individuals from harm (Robinson, 2024).
* There are also legal requirements that exist to report communicable diseases that have an effect on the health of the public

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30
Q

Administrative Safeguards

A
  • policies and procedures,
  • oaths of confidentiality,
  • privacy awareness training programs,
  • code of conduct,
  • and access request forms
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31
Q

Physical Safeguards

A

Physical safeguards refer to the security that we use in locations where personal health information is maintained.
◦ locked cabinets;
◦ key control;
◦ motion detectors and other intrusion alarm systems;
◦ fire suppression;
◦ secure shredding; and,
◦ fax machines in secure locations

32
Q

Technical Safeguards

A

Technical safeguards include computer
systems and controls like complex password requirements, audit
logs, backup, role based
access permissions etc.

33
Q

Use of Personal Health Info

A

You may only use the patient’s information for the purpose that it was provided at the time that you collected the information from the patient (Eaton, 2020).
* If you intend to use the patient’s information for a purpose that is different from the original purpose that the information was collected for, you likely need to receive the patient’s consent to do this
Viewing personal health information is the
same as using personal health information

  • You may view personal health
    information only when you have a need to
    know that information to provide a health
    service or to do your job (Eaton, 2020).
  • If you view personal health information “just to see” and don’t have an authorized need to access the information, this is a privacy breach
34
Q

Access Request

A

When a patient requests to have a copy of
their own records, this is an access request,
not a disclosure

35
Q

The Patient Record

A

The patient record is the principal document containing critical information you will need to manage each patient in the dental practice
* Whether you are communicating with a
patient by phone or in person, the patient
record must be available for reference
* A patient’s record is organized in a specific
order to allow the dental team to move from the patient’s personal information, to the diagnostic findings, and then finally the
documentation of treatment

36
Q

Importance of a Patient Record

A

Guides/directs dental care
* Basis for diagnosis and treatment plan
◦ Dentist
◦ Dental hygienist
* Evaluates response to treatment
* Insurance audits
* Evidence in a court of law
* Taxes
* Assists in forensic evidence

37
Q

Patient Registration Form

A
  • Patient information including full name, date of birth, address, telephone numbers (home,
    cell, work), employment information, spousal information, and emergency contact
  • Insurance information
  • Responsible party indicates who will pay for treatment
  • Patient signature and date
38
Q

Other Forms completed by patient (other then registration form)

A

Medical/Dental History Form
◦ provides an overview of the patient’s past medical and dental health conditions.
* Patient Consents - a) Disclosure (release of information) b) Treatment (informed consent)
* Privacy Policies
* Financial Policies

39
Q

Forms completed by Dental Staff

A

Diagnostic forms
◦ Physical Examination form which most often is used to record the patient’s vital signs

◦ Radiographic Examination

◦ Clinical Examination form which records the results of the intra- and extra-oral examination
Patient’s name and date of examination Charting of existing
restorations and present conditions
a) Extraoral Examination:
i. Findings of temporomandibular joint
b) Intraoral Examination
i. Charting of periodontal conditions
ii. Patient’s chief complaint
iii. Findings of occlusal evaluations
iv. evaluations
v. Comments

Informed Consent
◦ for specific treatment to be undertaken, such as consent to remove an infected tooth

Informed Consent:
a) Related to a specific treatment or procedure, provides the patient with the expected outcomes of treatment
and describes any possible complications that might occur
b) Commonly used for invasive or extensive treatment, such as in specialty procedures

  • Treatment Plans
    ◦ records the details of any planned treatment
    a) Record the plan of care on the treatment plan form
    b) Properly sequence to address all problems that were identified during examination and diagnosis portions of the
    patient visit.
    c) Treatment plan may change course if financial arrangements become a factor
  • Progress Notes - PARTS
    ◦ a record of actual treatment provided to the patient
40
Q

General Rules of Dental Record

A

Documentation should occur during or immediately after patient visits
Documentation should be made in chronological order
The use of unique abbreviations that can not be easily understood by others should not be used
Never include speculation or derogatory statements in a dental record

41
Q

How to maintain a legal document

A

Each component of the patient’s record
needs to be marked with patient’s name
* Health histories and vital signs need to be
updated regularly and should be
documented comprehensively
Use permanent pen
 Do not change pens in middle of an entry
* Write neatly and clearly
 For mistakes stroke out with one clean line, initial and date error.
 Scribbling incorrect information and/or erasing/using “white out” cannot be defended in a court of law.
* Ensure information is relevant and accurate
-Use uniform terminology and abbreviations
Record immediately and in order of treatment
 Ensure warning/caution indicators stand out
Pre-medications
Allergies
Phobias/Anxiety
 Whomever provided the service records in the chart
 All records must be dated, signed and/or initialed by the person who is recording the record

42
Q

Infection Prevention Control for Records

A
  • Paper records
  • This may include using plastic barriers to
    cover papers and pens (Boyd & Mallonee,
    2023).
  • Electronic records
    ◦ plastic barriers for computer keyboards
    and mouse, as well as disinfection of
    chairside monitors (Boyd & Mallonee,
    2023).
43
Q

Systematic Chart Entries

A

Assures that no details are missing from the patient’s record,
* Aids in ensuring records are sufficiently detailed,
* the use of acronyms such as or can provide guidance and uniformity in recordkeeping protocols

44
Q

RATPP (systematic chart entry)

A

RATPP
◦ R-reason
◦ A-anesthetic used
◦ T-treatment,
◦ P-post-operative care
◦ P-plan for next visit

45
Q

SOAP (systematic chart entry)

A

S.O.A.P
◦ S-subjective
◦ O-objective
◦ A-assessment
◦ P -plan

46
Q

PARTS **systematic chart entry USED BY SAIT*

A

PARTS
◦ P- problem or procedure
◦ A- assessment
◦ R- recommendations/prescriptions
◦ T- treatment
◦ S-subsequent advice

47
Q

What form records existing conditions in
patient’s oral cavity?

A

Diagnostic Form / Clinical Examination Forms

48
Q

What form may include information about
patient’s past experiences with dental
treatment?

A

Dental History

49
Q

What record’s the treatment provided during each visit?

A

Progress notes

50
Q

What form informs dental team of conditions that could be life-threatening to patient during treatment?

A

Medical History

51
Q

What form describes expected outcomes of
treatment along with possible complications?

A

Informed Consent

52
Q

PARTS details

A

PARTS notes are used in the SAIT DA program to standardize daily
chart entries:
P = Problem and/or Procedure: what procedure/treatment are you planning
on doing today? Identify any problems the patient may be concerned about.

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

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

S = Strategy/Subsequent advice: 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.

53
Q

Written Chart benefits

A
  • If there is power or software issue the chart is still accessible
  • File is portable for viewing in rooms without a computer
54
Q

Electronic Chart benefits

A

Standardize terms
* Increased speed of entry
* Encourages more detailed entries
* Increased legibility
* Introduces new ways to share information
* Maintains digital radiographs and photographs within record

55
Q

Filing Patient Records

A
  • Written
    ◦ In an area accessible
    only by authorized
    personnel
    ◦ Locked drawers/room
  • Electronic
    ◦ Requires more
    computers for
    authorized personnel
    ◦ Password protected
56
Q

Record Keeping

A
  • Detailed records are essential for continuity of care, safe treatment of patients, and for the protection of the dental healthcare professional.
  • The patient record must contain sufficient
    information to provide a record of informed
    consent, diagnosis, treatment plan, care
    provided, and postoperative instructions such that another health care provider can continue care
57
Q

Chart Audits

A

A chart audit is a method of reviewing
documentation techniques. It is performed to ensure accountability and competent record keeping and quality assurance of patient care

58
Q

Retention of Dental Records

A

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

59
Q

Appointment Records

A

A record of appointments showing for each
day the names of patients who received
professional services must be kept for a
period of at least two (2) years

60
Q

Privacy Breaches

A

Health Information has been or may be
accessed by a person
* Health Information has been or may be
disclosed to a person
* Health Information has been misused or will be misused
* The breach could be used for identity theft or to commit fraud
* The breach causes embarrassment
* The breach causes physical, mental, or
financial harm
* The breach damage an individual’s reputation
* The breach adversely affects the provision of a health service to the individual

61
Q

Privacy Impact Assessment

A

A privacy impact assessment (PIA) is a
process of analysis that helps custodians to
identify and address potential privacy risks
that may occur in the operation of a new or
redesigned project.
* A PIA is meant for proposed legislative
schemes, administrative practices, and/or
information systems that relate to the
collection, use, or disclosure of individually
identifying personal or health information

62
Q

The Health Information Act of Alberta defines “record”…..

A

The Health Information Act of Alberta defines “record” to mean health information in any form and includes notes, images, audiovisual recordings, x-rays, books, documents, maps, drawings, photographs, letters, vouchers, papers, and other information about an individual that is collected when a health service is provided to the individual, that is written, photographed, recorded or stored in any manner

63
Q

Each component of the patient record should be marked with…

A

patient identification and/or demographic information

64
Q

Remember, the dental record is.

A
  1. A method of communication.
  2. A legal document.
65
Q

Personal Information Protection and Electronic Documents Act (PIPEDA)

A

The Personal Information Protection and Electronic Documents Act (PIPEDA), sets national standards for privacy practices in the private sector. Alberta and British Columbia have both passed similar laws, known in each province as the PIPA (Office of the Privacy Commissioner of Canada, [OIPC], 2004).
Both the federal Act, PIPEDA, and Alberta’s PIPA focus on protecting personal information in the private sector.
PIPEDA applies to every organization across Canada when collecting, using, or disclosing personal information while carrying out a commercial activity within a province unless a province passes legislation that is substantially similar to PIPEDA (based on the same purposes and rules).

Where health information is being transferred across provincial boundaries in relation to commercial activity, such as in the case of obtaining payment from an insurance company located outside of Alberta, the provisions of the federal Personal Information Protection and Electronic Documents Act (PIPEDA) may apply (CDSA, 2016a).

66
Q

Dental Records

A

Maintaining accurate and complete dental records is essential to any dental practice and is a basic requirement of providing patient care. Information about the patient’s general and oral health must be obtained before a thorough diagnosis and treatment plan can be formulated. The patient’s dental record must be available for reference whenever you are communicating with the patient, be it in person, on the phone, speaking to another healthcare professional, or an insurance company (Robinson, 2024).
A dental record must record an accurate picture of the patient’s general health, oral/dental status, and any patient concerns and requests. It must include the clinical findings, diagnosis, proposed treatment plan, and treatment performed, as well as all supporting documentation including the informed consent process (CDSA, 2016).

The Health Information Act of Alberta defines “record” to mean health information in any form and includes notes, images, audiovisual recordings, x-rays, books, documents, maps, drawings, photographs, letters, vouchers, papers, and other information about an individual that is collected when a health service is provided to the individual, that is written, photographed, recorded or stored in any manner

67
Q

a dental record consists of…

A

A dental record, therefore, consists of several different components, such as:
Required information

demographic information,
medical history and vital signs,
dental history,
risk assessment (e.g. periodontal, caries, oral cancer, tobacco and/or substance use and diabetes),
clinical assessment and diagnosis,
progress notes for each patient visit,
treatment recommendations and treatment plan,
informed consent, and
privacy and confidentiality measures (Boyd & Mallonee, 2023).
Additional components

study models,
orthodontic records,
laboratory orders and test results, and
referral records and copies of consultation with dental specialists or medical practitioners

68
Q

Accurate dental records are important for several reasons:

A

Provide a means of communication between members of the dental health team and the patient.
Facilitate treatment planning and continuity of care
The basis for the evaluation of the quality of care and effectiveness of patient care practices.
Data can be used in research and education.
Considered legal evidence in any legal or forensic situation

69
Q

Examples of forms used in a dental record:

A

Examples of forms used in a dental record:

patient registration
medical/dental history forms
consent forms
diagnostic information gathering forms
clinical examination forms
treatment plan forms
progress notes

70
Q

Privacy Breaches under the HIA

A

A privacy breach means a loss of, unauthorized access to, or unauthorized disclosure of individually identifying health information (Alberta Queen’s Printer, 2022). If a privacy breach occurs, and a custodian determines there is a risk of harm to the individual, the custodian must notify:

·Individual(s) affected,
·The Information and Privacy Commissioner, and
·The Minister of Health (Alberta Queen’s Printer, 2022).

Affiliates must also notify the custodian when a privacy breach occurs

71
Q

Risk of Harm - breaches

A

Health Information has been or may be accessed by a person
Health Information has been or may be disclosed to a person
Health Information has been misused or will be misused
The breach could be used for identity theft or to commit fraud
The breach causes embarrassment
The breach causes physical, mental, or financial harm
The breach damage an individual’s reputation
The breach adversely affects the provision of a health service to the individual (Office of the Information and Privacy Commissioner

72
Q

Electronic Records

A

Electronic Records
Computerized records have recently provided a quicker, more convenient, and better-organized replacement for written records (Boyd & Mallonee, 2023).
Electronic records must comply with all requirements of traditional paper records (CDSA, 2016).
Electronic records require computer terminals where only authorized personnel can access the required information (Boyd & Mallonee, 2023).
Dental personnel must have individual logins and passwords to access the data (CDSA, 2016).
Computer terminals should be directed away from the view of unauthorized persons (Boyd & Mallonee, 2023).
A variety of programs are available. Electronic records have the potential to:

standardize the terminology used for data entry,
improve efficiency - speed up entry of information and encourage more comprehensive information,
increased legibility
provide new ways for sharing information with dental specialists and other multidisciplinary team members
maintain digital radiographs and photographs within the patient record,
provide new ways of analyzing clinical information and treatment outcomes, and
provide easier and faster access to clinical information

73
Q

Written Records

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Historically, dental healthcare records have been maintained in written form.
Handwritten records are to be recorded legibly and written in ink (Robinson, 2024)
Mistakes are corrected by placing a single line through the error and writing the correction rights after and signing (Boyd & Mallonee, 2023).
White-out should not be used in a written record (CDSA, 2016).
If a late entry is necessary, the new information should follow the most recent entry, it is to be noted as a late entry and should include the date and time that the late entry was made (Boyd & Mallonee, 2023).

74
Q

several essential components of a clinical record that include:

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all entries on a patient record are dated;
all entries on a patient record are signed, initialed, or otherwise attributable to the writer and treatment provider;
all paper-based entries on a patient record are recorded by hand in permanent ink, typewritten, or printed from a digital file;
accurate general patient information that is periodically updated;
a medical history that is periodically updated and at a minimum verbally reviewed prior to each appointment and noted within the chart;
a dental history;
an accurate description of the conditions that are present on initial examination, including an entry such as “within normal limits (WNL)” or “no abnormalities detected (NAD)” where appropriate;
an accurate description of ongoing dental status at subsequent appointments;
a record of the significant findings of all supporting diagnostic aids, tests, or referrals such as radiographs, diagnostic casts/models, and reports from specialists;
all clinical diagnoses and treatment options;
a record identifying all reasonable treatment planning options including no treatment and that they were discussed with the patient;
the proposed and accepted treatment plan;
a notation and documentation that informed consent was obtained;
assurance that patient consent was obtained for the release of any and all patient information to a third party;
a description of all treatment that was performed, materials and drugs used, and where appropriate, the prognosis and outcome of the treatment;
details about referrals;
an accurate financial record;
the patient, caregiver, or guardians’ signature in most cases on the medical history, privacy policy, and informed consent documentation; and
a copy of all patient communications.

75
Q

Chart Audit

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A chart audit is a method of reviewing documentation techniques. It is performed to ensure accountability and competent record-keeping and quality assurance of patient care.

76
Q

Filing Storage of Patient Record

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In all storage systems, the privacy of a patient’s information must be respected.

For written records, a filing system is needed that provides accessibility to health records by authorized personnel. They are to be secured in a locked cabinet or room when staff is not on-site and able to monitor access (Boyd & Mallonee, 2023).

Electronic records must store the original data in a read-only format from within the dental program itself, but protect the data files for entry and alteration from the database. Electronic records must have backup files on a removable medium that allows for data recovery and provides by other means reasonable protection against loss, damage, and/or inaccessibility of patient information. The dental professional using the electronic record must be properly trained and have technical competence with the computer program (CDSA, 2016).

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 (CDSA, 2016). A record of appointments showing for each day the names of patients who received professional services must be kept for a period of at least two (2) years (CDSA, 2016).