Record Keeping

Question 1

how do you make alterations on records?

Answer 1

score out with a single line with date, time and sign

Question 2

how should you identify each patient on each page?

Answer 2

name, DOB, NHS number

Question 3

what 12 things need to be included in a record?

Answer 3

1. CO - chief complaint
2. HPC - history of chief complaint
3. MH - medical history
4. DH - dental history
5. SH - social history
6. FH - family histories
7. habits
8. IO and EO examination
9. Investigation records - charts, study models, radiographs, vitality tests
10. diagnosis
11. conversation about diagnosis and proposes treatment
    - outline the benefits, risks and alternative treatment
12. consent - agree or rejected with reason

Question 4

How Should a Radiograph be Reported? (5)

Answer 4

Type of Radiograph
Date
Justification
Quality
Findings
1. teeth present
2. radio-opacities
3. radiolucencies
4. periodontal
5. other findings

Question 5

when must you check for changes in medical history?

Answer 5

at the start of every visit

Question 6

what does the extra-oral assessment comprise of?

Answer 6

face and head
neck
TMJ

Question 7

What do you check for in an intra-oral examination?

Answer 7

soft tissues
- any lesions, absence of pathology

hard tissue
- charting
- endo teeth
- occlusion
- non carious tooth tissue loss

Periodontal

Prosthodontic

Question 8

What do you Report in a Periodontal Assessment?

Answer 8

• BPE
• presence of bleeding, mobility and furcation
• calculus
• sensitivity
• colour and contour of gingivae
• plaque and oral hygiene measures

Question 9

What do you Report on Prosthodontics Recording?

Answer 9

• the type of prosthesis and material used
• teeth present
• retention
• stability

Question 10

How should you report an emergency patient?

Answer 10

• state in record that is it emergency exam
• identify cause and management
• record any treatment done by another practise or hospital
• if pt attends different practise, write a letter to their GDP to inform

Question 11

How should you report dental trauma?

Answer 11

write the history of complain in the patients recollection ACCURATELY

Question 12

why is it important to have such accurate notes?

Answer 12

prevent legal action going wrong

Question 13

How should you report an avulsed tooth?

Answer 13

details of trauma, how and where
- how long the tooth has been out the mouth
- how the tooth was transported to practise
- if tooth is contaminated
- measure the root of tooth

Question 14

can you obtain valid consent from children?

Answer 14

no , must have parental responsibility

Question 15

how do you report an oral lesion? (9)

Answer 15

§site
size
shape
distribution
definition
colour
constituency
texture
history