Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Intro to Patient > The Medical-Dental Chart > Flashcards

The Medical-Dental Chart Flashcards

1
Q

Why to we need a record?

A

document the course of illness and any treatments provided
communicate between all involved doctors and any other consulting medical professionals
provide continuity of care
to research diseases and treatments
to collect statistics across populations

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What is the chart?

A

written record of treatments, diagnoses, plans, and patient response
tool for storage and communication of treatment
-can see how conditions/illnesses have changed over time
educational tool

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Why is the record important?

A

record of the medical encounter
legal document
professional standard
ethical obligation
provides information to support diagnosis
organized reference for patient information
-helps to not get overwhelmed with patient load

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Record of the Medical Encounter

A

permanent evidence of conversations, treatments, and decisions made with the patient
allows for addition of detail specific to each situation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Data Types that the Record Includes

A 
administrative data 
     -demographic 
     -socioeconomic 
legal data
     -consent for treatment 
     -release of information consent (especially between healthcare providers) 
financial data 
     -insurance 
     -other payment information 
clinical data
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Patient Identification

A

name
-including previous and preferred names
**helps to not confuse patients
**helps to not have multiple files for same patient
***helps other providers if listed under diff. name
sex, gender, preferred pronouns
-sex, age, and race can aid in diagnosis later on
race
date of birth
-helps identify patient as who they say they are
address, telephone(s), email, emergency contact
-contacts are important in order to get in touch with patient
names of treating physicians
-including what they’re seeing them for and contact info for them

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Medical Record Number (MRN)

A

individualized identification number that is assigned numerically in the order in which new patients are received
should be the primary way of identifying the patient when discussing them within the office

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Record as a Legal Document

A

all healthcare providers are required to record all treatments and supporting info
can protect against malpractice cases
justifies the care that was done

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Forensic Odontology

A

dental records and treatment details may be used as investigative tools during legal proceedings
-identify perp or identify decomposed victim
has been used to identify perpetrators of crimes
-State of FL vs. Ted Bundy
-State of New Jersey vs. Jesse Timmendequas (Megan’s Law case)
-State of California vs. Marx

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Legal Uses

A

insurance cases
-proof of injury, disability, or treatment
worker’s compensation
-details of injury or disability suffered
-treatment provided and expected healing
personal injury claims
-pursuit of damages through harm or neglect
malpractice claims
-negligence or improper treatment
will cases
-proof of competency (of person distributing or reading)
other criminal cases
-assault
-unexplained death
-sexual harassment
-mental competence

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Record as an Aid in Diagnosis

A

symptom development over time
proper historical record clarifies unseen trends
complete picture of the patient
at population level, can clarify incidence and evolution of conditions and treatments

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Clinical Components of Medical or Dental Chart

A 
patient identification 
CC
history of present illness 
medical history 
physical exam 
dental chart 
assessment 
imaging 
laboratory studies 
treatment plans 
notes 
attachments 
     -consents 
     -referrals 
     -outside records
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

CC

A

record source of history and their reliability
document in their own words
focus on one purpose for the current visit
should be reflected, even if straightforward

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

HPI

A

should be brief, clear, coherent, complete, in a logical order, and focused
should include onset, duration, timing, location, severity, previous treatments, general symptoms and associated factors
will be simpler for routine visit
-time since last visit
-nature of previous treatment
-patient’s perception of their oral health status

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Medical History

A 
DETAILED ACCOUNT
illness 
injury 
operations 
hospitalizations
     -for the above two, important to note date, procedure and healing
medications 
allergies 
family history 
social history 
review of systems 
     -can hint at an unrelated condition or come back to assist in diagnosis of CC
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Modifications to Dental Treatment

A

should be featured prominently in the chart (avoid mistakes)
some conditions require modifications
-laboratory evaluation before treatment
-avoidance of invasive treatment
-antibiotic prophylaxis prior to care
-rarely modifications to normal medication regimens

17
Q

Physical Exam

A

vital signs and statistics
general description
-appearance
-mental state
-notable traits
extraoral exam
-record ONLY what was assessed (if you didn’t look don’t record it)
intraoral exam
organization may be specialty-specific
use patient signs and symptoms as clues to localize findings
may include diagrams when well documented and clearly labeled

18
Q

Dental Chart

A

full scope of current oral status
existing teeth with condition
planned treatment (often in red)
completed restorations (whether by your office or prior to their arrival)
periodontal examination findings
constant and evolving portion of the medical record

19
Q

Assessment

A

most likely diagnosis followed by other options (differential diagnosis)
-what is causing CC
-ALWAYS consider worst case scenario
secondary diagnoses listed underneath in order of severity
may contain definitive diagnosis, once reached
consider which to combine and which to keep as separate complaints
-based on age, history, findings, physiology
ideas decided logically from history
-distinguish between pathology, pathopsychologic, and psychopathologic processes
-note if assessment breaks with the norm, and note why you are still considering this diagnosis

20
Q

Pathology

A

physical problem

21
Q

Pathopsychology

A

psychology affects the problem

22
Q

Psychopathology

A

no evidence of pain or problem (phantom pain)

23
Q

Diagnoses in Medicine

A

standardized using International Statistical Classification of Diseases and Related Health Problems
-currently on 10th edition (ICD-10)
alphanumerical codes correspond to injuries, illnesses, conditions, and past procedures
allows storage, retrieval, and analysis of data at population and practice level
at least one must be entered for every medical encounter

24
Q

Diagnoses in Dentistry

A

less well defined as medicine
-ICD-10 codes contain limed specificity in diagnosis
-no similar global system for standardization exists
ICD-10 codes may be used for billing purposes
code on Dental Procedures and Nomenclature (CDT)
-accepted by all insurance in US for billing
-standard maintained by ADA and nationally recognized for documentation and billing
Systemized Nomenclature for Dentistry
-more robust diagnosis system, not universally recognized
-neither as widespread as ICD-10, can lead to communication issues

25
Q

Studies

A

prescription and rationale for obtaining additional diagnostic information
-labs
-radiographs
-studies
start simple to rule in or out possible diagnoses
-effective utilization of resources (time and money)
always document need for these inquiries, pre- and post-exam working diagnoses, and findings

26
Q

Treatment Plans

A

nature and sequence of procedures
-emergency
-surgical
-periodontal
-endodontic
-restorative
-orthodontic
-fixed prosthetic devices
-removable prostheses
sufficient detail that another may complete the proposed therapy
sensitive to patient desires, current conditions, financial abilities, competing responsibilities, family dynamics
may include plans for dealing with psychologic comorbidity (depression, anxiety, etc)
not fixed - will change based on patient symptoms, desires, and status

27
Q

Notes

A

should be completed at the end of every visit
summary of treatment provided at each visit
-presenting complaints
-current conditions/status (even emotional)
-history
-exam findings (including pertinent negs and positives)
-assessment (differential diagnosis and patient response to proposed treatment)
-detail of procedures performed (including preventative care measures)
-need for/interpretation of studies
-any medications provided (pre and post)
-complications (even lack of complications)
-instructions to patient (procedure care, education)
-next appointment

28
Q

SOAP Format

A

can do this as a general format for whole note or for each CC
Subjective - chief complaint, problem, HPI
Objective - exam, findings, labs, studies
Assessment - diagnosis, impression
Plan - referral, tests, additional imaging

29
Q

Attachements

A 
consents 
     -can be general for all treatment or specific consent for certain treatments 
consultations 
     -dental 
        -evaluation 
        -diagnosis 
        -treatment (maybe send to specialist) 
    -medical 
        -further info 
        -physician perspective - but remember WE ARE the experts
        -refer for treatment 
lab reports 
surgical records 
imaging or studies 
     -must always be interpreted (should self-interpret)
     -organized to avoid repeat exams
30
Q

Who Owns a Chart?

A

In US (and many other countries)
-all content belongs to the patient as confidential communication
-physical record belongs to the provider (or their organization)
-some states do not legally record a definition for ownership of the medical record, this is the default
patients have a right to their information and to ensure its accuracy
-may petition to have inaccurate information amended

31
Q

Who has Access?

A

patient
treating physicians
-including those treating an unconscious patient in emergency
-including trainees
anyone to whom the patient grants access
legaal guardians
researchers, when patient has given permission
-or those conducting research when all identifying information has been removed
billing and administrative personal (limited)

32
Q

Legal Access to the Information

A

patient information may be provided to legal authorities when there exists a compelling reason to believe that withholding information would result in harm to the patient or another
information may not be shared merely for the purposes of initiating legal charges
otherwise, patient information is guarded under strict confidence with laws and professional codes

33
Q

HIPAA

A

health information probability and accountability act
enacted by Congress in 1996
lays out patient rights to see their records, know who has accessed it, and how it has been used
protects patients from having information shared
-health conditions
-medications
-treatment history
-billing and insurance information
defines repercussions for breaking the rules
clarifies additional security requirements involved in the use electronic records

34
Q

How Long Does the Record Last?

A

hospitals must retain patient records for 7 years
-for minors, 7 years after patient turns 18
in many jurisdictions, one must forever maintain
-full name and date of birth
-treatment or hospitalization dates
-name of treating provider(s)
-diagnoses associated with treatment
-procedures performed
-discharge summaries for hospital admissions
it is also best practice, particularly in the digital age, to retain content

35
Q

Accuracy and Completeness

A

falsification of a medical record is a FELONY
records must be kept of every patient treated in any capacity, including emergency services
all records must be accurate and complete
dental services must equally be recorded and included in medical chart

36
Q

Paper vs. Electronic Charts

A

some dental offices continue to employ paper charts
much of medicine and dentistry has transitioned either in part or in full to electronic medical records (EMR)
encouraged by the US Congress in the Health Information Technology for Economic and Clinical Health (HITECH) Act
-contained within HIPAA
-provides up to $44,000 per physician under Medicare, or up to $65,000 over 6 years under Medicaid
-decreased Medicare and medicaid reimbursements to doctors who failed to use EMRs by 2015

37
Q

Benefits of Electronic Medical Records

A 
eliminates need for storage space 
clarity of records 
improved organization 
provides additional security to records 
easier to share records within and between departments
38
Q

Electronic Record Keeping in Dentistry

A

Dentrix
axiUm
MacPractice
Eaglesoft

Intro to Patient (10 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions