Wk 13: Clinical Records

Question 1

why is it important to keep good dental records

Answer 1

1. To aid and enhance patient care
   - Facilitates diagnosis and treatment planning
2. To help you recall at a later date what events took place and the reasons for your decisions
3. Ensure continuity of care
4. Patient Safety
5. Clinical Governance and Audit purposes
6. Forensic identification purposes
7. Medico-legal purposes

Question 2

What is included in the history component of an 011

Answer 2

Chief complaint
history complaint
medical history
dental history
relevant social history

Question 3

What’s included in the examination portion of an 011

Answer 3

Extra oral
-lymph nodes, glands, symmetry,tmj

intra oral
-CPITN, Hard tissues, soft tissues

• generation of an odontogram

Question 4

What is included in the assessment portion of an 011

Answer 4

Radiographs, special test, diagnosis

Question 5

What is included in the information and discussion of an 011

Answer 5

Treatment options given
-risks, benefits, advice,

Treatment declined

informed consent obtained

Question 6

What is included in the treatment plan section of an 011

Answer 6

Written organized treatment plan

treatment carried out
- post op instructions
- adverse reactions
- steps of treatment

Prescriptions
- drugs and laboratory

Question 7

What is included in the follow up portion of an 011

Answer 7

Treatment to be performed and when

further actions (referrals

Recall intervention

Question 8

Describe what an 011, 012,013, 022, 114

Answer 8

011- comprehensive oral exam
012- periodic oral exam
013- limited oral exam
022 Intra oral xray
114- Removal of calculus (first visit)

Question 9

what does CASE stand for

Answer 9

CLEAR
ACCURATE
SUFFICIENT
EFFICIENT