Types of patient records Flashcards
1
Q
Personal details
A
identify the correct pt who requires the assessment, either hard copy or computer pt file. Should include: title, full name, dob, address, home + telephone numbers
2
Q
In hospitals
A
an A4 booklet with various page inserts
3
Q
In practice
A
typical NHS FP25 style record card
4
Q
Medical history
A
all pts have a full medical history taken when they initially attend, + this is updated. full details of past + present illnesses - signed and dated.
some pts may have lesion affecting oral mucosa that indicates they are suffering from disease or medication
5
Q
Dental charts
A
Tooth charts, BPE, periodontal assessment
