Ethics/Documentation Flashcards
Why is proper documentation important in dentistry?
It helps the dental team function cohesively.
What is the ethical, moral, and legal responsibility of healthcare professionals?
Treat patients safely and provide legal protection for the practitioner.
What is the patient’s health record?
A vital aspect of legal documentation.
What are your responsibilities for health record documentation?
Ensure it is accurate, legible, grammatically correct, and spelled correctly.
Is the health record admissible in court?
Yes, it is evidence in a court of law.
What types of patient communication must be documented?
Verbal, text, and email interactions.
What must be documented about treatment plan options?
All options presented by the dentist, dental hygiene faculty, or yourself.
What does HIPAA stand for?
Health Insurance Portability and Accountability Act of 1996.
What must be documented about care provided?
All care provided, who provided it, and specific treatments like local anesthesia or laser procedures.
What right do patients have regarding their health information?
The right to keep it private.
What is the purpose of HIPAA?
To create national standards protecting sensitive health information from unauthorized disclosure.
What must patients do regarding caregivers in the operatory?
Provide permission for caregivers or others to accompany them. (caregiver consent from)
How do patients control the use of their health information?
They state how it will be used and by whom.
What does HIPAA require to protect patient information?
Implementation of administrative, physical, and technical safeguards.
What are your responsibilities?
- Complete annual HIPAA training
- Lock your computer anytime you leave the computer area,
- Only access the patient chart you need for the appointment.
- Quiet voices when discussing patients with faculty or other students
- Shredding papers that contain any protected health information
- Using strong passwords
- Using current anti-virus software
- Locking offices and cabinets
- Using privacy screens