Lesson 3 Flashcards
Information gained from the patient’s initial telephone call to the office
telephone form
Information about the patient’s general total health
medical history form
Plans for future dental work
treatment plan
Instructions to the dental lab regarding a prosthesis
laboratory form
Risks and benefits of dental surgery
consent form
Risks and benefits of dental surgery
consent form
Charting symbols taken on the patient’s initial visit
clinical examination form
Charting symbols taken on the patient’s subsequent visits
recall examination form
Information about the patient’s past dental experiences
dental history
Checking the document to make sure it is ready for filing is called:
inspecting
Separating records and documents into categories according to filing method and location of the files is called:
sorting
Noting information in more than one place while filing is called:
cross-referencing
Separating documents alphabetically into already created categories before filing is called:
sorting
The record that introduces the patient to the practice and provides demographic and insurance information is the:
registration form
Which of the following is not a necessary form in the clinical record? registration form, medical history form, clinical examination form, problem priority list
problem priority list
Which of these forms does not contain a dental tooth chart? clinical examination form, recall examination form, treatment plan, all contain a dental tooth chart
treatment plan
The form used to record the course of treatment for the patient is the:
progress notes
The form used to prioritize treatment that needs to be performed is the:
problem/priority list
Risk management is a process that:
identifies conditions that may lead to alleged malpractice
One of the major reasons that legal actions are decided in favor of the patient is:
poor record keeping
Characteristics of clinical record entries include all of the following except: signature, date, and identification number of person making the entry; use of standard abbreviations; consistent line spacing; marking out an error and writing over it
marking out an error and writing over it
A cast of the patient’s mouth used as a tool in treatment planning is called a:
diagnostic model
Which is not true about entries made into the clinical record: they must be in ink; they must be completely obliterated if changed; they must be legible; they must be signed and dated
they must be completely obliterated if changed
The arrangement of name, subject, or number when filing refers to:
indexing