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COLLEGE OF ALBERTA DENTURISTS

2008

Patient Recordkeeping Manual

WWW . C O L L E G E O F A B D E N T U R I S T S . C A

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Table of Contents

Introductory Items

Section Title Page(s)

1 Introduction 1 2 Disclaimer 2 3 Use 2 4 Risk Management 2 5 Definitions 3 6 Patient Charts & Patient Records 4 7 Basic Recordkeeping Assumptions 4 8 Patient Recordkeeping Principles 5 9 Privacy Legislation 6 10 Confidentiality of Information 6 11 Use of Symbols, Abbreviations, & Terminology 7-9

1. Table of Symbols 7 2. Table of Terminology & Abbreviations 8 3. Natural Dentition Identification 9

12 Consent 10-13 1. Informed Consent 10 2. Implied Consent 10 3. Expressed Consent 10 4. Consent of Dependent Adult Patients 12 5. Consent of Minor Aged Patients 13

13 Patient Signatures 14

Requirements

14 General Patient Information Guidelines 15 15 Medical History Information Guidelines 16-17 16 Dental History Information Guidelines 18 17 Clinical Examination 19 18 Diagnosis, Treatment Planning & Prognosis 20-21

A. Diagnosis 20 B. Treatment Plan 20-21 C. Prognosis 21

19 Personal Comments 22 20 Information Presented to the Patient 22

Continued on next page

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21 Choice of Patient Chart 23-24 1. Extraoral Examination 23 2. Intraoral Examination 23 3. Odontogram 23 4. Radiographs 24 5. Periodontal Screening Record & Tooth Mobility Record 24 6. Partial Denture Prescription Forms 24 7. Financial Ledger 24

22 Progress Notes 25-26 A. Entering Information into the Patient Record 25-26 B. Entering Personal Comments into the Patient Record 26

23 Progress Notes Method 27-30 A. Multiple Appointment Procedures 27-28 B. Single Appointment Procedures 29 C. Sample of Patient Notes Entries 31

24 Documenting Referrals 31 25 Recall (Continued Care) 31 26 Electronic Recordkeeping 32

27 Financial Records 33 28 Correction of Entries 34 29 Forensic Matters 34 30 Retention of Patient Records 35

1. Deceased Patients 35 2. Sale of a Practice 35 3. Closure of a Practice 35 4. Appointment Schedule Records 35

31 Security, Storage & Disposal of Patient Records 36-37 1. Security of Records 36 2. Storage of Inactive/Achieved Records 36 3. Disposal 37

32 Access to the Recorded Information 38-39 1. Patient Access 38 2. Dependent Adult Patient Access 39 3. Minor Aged Patient Access 39

33 Specific Situation Considerations 40 1. Refusal to Treatment and/or Referral 40 2. Dissatisfied Patient 40 3. Termination of Treatment 40

34 Other Required Records 41

Continued on next page

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These Guidelines were Approved by Council, on April 07th, 2008.

Copyright© April 09, 2008, Registration Number: 1057342.

Example Chart Documents & Forms

35 Sample Chart Documents 42-67 Personal Information Protection Act Consent 43 Personal Information Form 44 Medical History Form 45-46 Dental History Form 47-48 Medical & Dental Histories Update Form 49 Extraoral Examination Form 50 Intraoral Examination Form 51-52 Implantology & Pathology Form 53 Evaluation of Existing Dentures Form 54 New Denture Registration Information Form 55 Odontogram 56 Periodontal Screening & Record & Tooth Mobility Record 57 Progress Notes 58 Treatment Plan Options Development Form 59-60 Dental Insurance Company Form 61 Partial Denture Prescription Form 62 Financial Record 63 Financial Terms Agreement Form 64 Credit Card Authorization Form 65 Biohazard Waste Disposal Record 66 Sharps Disposal Record 67

Example Referral Forms

36 Sample Referral Forms 68-71 Referral Form 69-70 Radiograph Referral & Requisition Form 71

Bibliography

37 Bibliography 72-73

Acknowledgements The College would like to thank those individuals who assisted in the development of this manual. Whether it was a contribution of information, wording, images, reviewing, or practical experience in implementing the procedures, their contributions have been instrumental in creating this outstanding recordkeeping manual. For that, we acknowledge the following (in alphabetical order): Walter A. Assmus, DD Richard O. Donily, DD

F. Charles Gulley, DD Misty B. Norton, DD

Robyn Roberts, B.Ed, RDA Blair Maxston, LLB Michael K. Weiss, DD Shaun H. Yandt, DD

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1. Introduction This Patient Recordkeeping Manual contains requirements and methods for patient recordkeeping. It has been developed by the College of Alberta Denturists and provided to the Members of the College of Alberta Denturists, to assist them in meeting their professional, ethical and legal requirements for patient recordkeeping.

Good records do not only help to facilitate good patient care, but also provide for the continuity of care for the patient.

All patient records must be organized using a systematic methodology. If the original recording denturist is unavailable or has sold the practice, a subsequent denturist should be able to easily review a patient record, understand what has transpired with that patient, and continue to provide necessary care for the patient. Further, in the event of a situation where the patient record is being examined by a third party, (such as in matters of conduct or malpractice), the record will become an essential part of the practitioner’s defence (or lack thereof).

It is essential that the Members read and understand this Manual, and that they take any necessary steps to ensure that their practice meets or exceeds the requirements.

The requirements in this manual are to be considered as a minimum standard for patient recordkeeping and as such, all Alberta Denturists are expected to abide by the requirements in their provision of professional services to patients. It is the College of Alberta Denturists’ position that these requirements are flexible enough for the Members to exercise reasonable professional judgement with respect to specific patient situations that may occur in day to day practice.

This manual contains recordkeeping requirements and parameters which the College of Alberta Denturists (or other health regulatory bodies), may utilize in determining whether or not an individual practitioner has met the appropriate standards of practice in provision of services, and further, that the inherent professional responsibilities of patient recordkeeping have been achieved and maintained.

Patient recordkeeping must comply with all applicable legislation, such as the Alberta Health Professions Act, Personal Information Protection Act and Health Information Act.

This manual additionally contains examples of various parts of a chart, which collectively would form part of the patient record. The Members are free to utilize the examples in their practice if they so desire (see Sections 2 & 3 prior to such use).

Accurate, clear, concise, legible, consistent and chronological patient records are part of providing safe, appropriate and quality patient care.

Not only does it indicate a level of professionalism of the providing denturist, it can also be the denturist’s best defence if a claim of negligence and/or

unprofessional conduct is alleged against the denturist.

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2. Disclaimer This manual contains information for consideration and implementation by the Members. It does not however, imply or cannot be interpreted as implying legal opinion or advice.

Further, the requirements in the manual are a summary of good general recordkeeping practices, but are not intended to be exhaustive. As such, all Members should seek their own independent legal advice for issues related to their patient charting, recordkeeping, record protection and retention, transfer, disposal, etc.

The College accepts no responsibility for the use or lack of use of the information and/or the forms contained in this manual.

3. Use This Manual is provided for use by the Members of the College of Alberta Denturists only. No duplication in whole or in part, or use by any third party is allowed, without first obtaining the written consent from the College of Alberta Denturists.

Copyright© College of Alberta Denturists - April 09, 2008, Registration Number: 1057342.

4. Risk Management The requirements of patient records as related to their documentation, accuracy, release, storage, retention, etc., has become increasingly more demanding for all health care providers.

It is essential that all denturists are familiar with the requirements of adequate patient recordkeeping, as must any and all of their staff. Adherence to the protocols for proper recordkeeping must be an integral and paramount procedure in any denture clinic.

In the event of an audit, complaint or malpractice suit, the practitioner’s records become one of the most important pieces of evidence for their defence or conversely, for their lack of defence.

Adages such as “never charted-never done” and “no record-no defence” sum up the necessity of adequate records. There is Canadian case law where judges have found accurate, clear, concise and detailed patient records to be a “testament” to the high level of care provided by the practitioner.

It is imperative to note that although a practitioner may delegate the entering of information into a patient chart and/or the patient record, the attending practitioner is ultimately responsible for any and all information recorded (or not recorded) in the patient chart and the entire patient record.

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5. Definitions

The following provides definitions of wording used in this document: College: Refers to the College of Alberta Denturists.

Denturist: Refers to a Regulated Member of the College.

Intern: Refers to an Intern Member of the College.

Student: Refers to a student enrolled in a Denturist Technology Program of studies approved by Council.

Members: Individuals registered with the College of Alberta Denturists as Regulated Members, Provisional Regulated Members, or Intern Members.

Patient: The individual whom is receiving the healthcare services.

Practitioner: Refers to a denturist or other health care provider.

Responsible Refers to a guardian, parent, or other similar legally responsible person. Individual:

Staff: Any individual employed by the Regulated Member or other practitioner.

Informed Consent: As defined in this document.

Implied Consent: As defined in this document.

Expressed Consent: As defined in this document. Patient Chart: As defined in this document.

Patient Record: As defined in this document.

Recordkeeping: Refers to all matters pertaining to the patient chart and record.

The following defines the qualifying words used throughout this document:

Must/Shall/Only/ Indicates a direct need and or requirement; these are a Will/Required: compulsory item and therefore mandatory.

Should: Indicates a recommended item to achieve the minimum standard; it is desirable. May/Could: Indicates an item which is left to professional discretion.

Appropriate / Indicates an item where professional judgement is to be used. Pertinent:

Prudent: Indicates an item which should be handled practically and judiciously. The following are abbreviations which appear throughout the document: HIA: Health Information Act.

HPA: Health Professions Act.

PIPA: Personal Information Protection Act.

PIPEDA: Personal Information Protection and Electronic Distribution Act.

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6. Patient Charts and Patient Records The College considers a PATIENT CHART as patient specific information and items pertaining to an individual, which includes:

All written or electronic information, notes, records, consents, documents, referrals, laboratory prescriptions, photographs, test results relating to a patient’s treatment; &

All written or electronic information, notes, records or documents regarding the financial, insurance and business matters relating to a patient and his/her treatment; &

All radiographs. The College is of the view that patient charts have four general purposes:

1. Managing Patient Care. This would include documentation pertaining to the start of the denturist-patient relationship (first appointment and the initiating of a patient record) and any ongoing treatments.

2. Documenting Business Aspects. This includes the financial records related to services provided and information pertaining to applicable public and/or private insurance aspects of providing treatment for that patient.

3. Communicating Patient Information. This would be for authorized communication within a denture clinic and to third parties (including other denturists/healthcare providers) via PIPA consent.

4. Providing Evidence. Presented as evidence in malpractice or other litigation and in professional conduct processes and proceedings.

The College considers a PATIENT RECORD to include: The patient chart; & Diagnostic model(s) and master impression(s) when salvageable and appropriate. The appointment book/schedule, (collectively by calendar-not separate per individual).

7. Basic Recordkeeping Assumptions The following are the basic assumptions related to patient recordkeeping:

Patients have a right to expect that the information contained in their patient record will be maintained as confidential at all times, by the denturist and any staff as per PIPA and HIA.

Patients have the right to obtain a copy of their records or to review their record in its entirety.

Distribution/sharing of any information in the patient record will only be done if consented to by the patient and further, only in a discretionary manner to ensure the continuity and required level of care for the patient, or as required by law.

Transfer of patient records from one practitioner to another will only be done if medically necessary or in the “selling” of a practice.

Eventual disposal of a record will only be done after the expiration of the required retention period, and then in such a manner as to ensure the confidentiality of the information is maintained, (see Section 31, Page 36).

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8. Patient Recordkeeping Principles

It is understandable that required or requested treatments will vary dependent on the individual patient and as such, the amount of information and the depth of detail will also vary. However, the following are the minimum requirements of what you must record for each patient:

1. PIPA consent form signed and dated: (see Section 9, page 6);

2. Complete and accurate general patient personal information: (see Section 14, page 15);

3. Complete and accurate medical history - which is updated appropriately: (see Section 15, pages 16-17);

4. Complete and accurate dental history - which is updated appropriately: (see Section 16, page 18);

5. Clinical Examination findings with an accurate description of presenting conditions at initial examination: (see Section 17, page 19);

6. A record of any significant findings by the practitioner of study models, referrals, radiographs, tests, and any significant findings from the reports received from general dentists, family physicians and/or medical/dental specialists;

7. The practitioner’s diagnosis: (see Section 18, page 20);

8. The recommended treatment plan(s) and the approved treatment plan: (see Section 18, pages 20-21);

9. A record that consent was provided for the treatment and where appropriate, that expressed consent is in writing: (see Section 12, pages 10-11);

10. Date specific, (and if prudent, time specific), detailed progress notes, signed/initialled by the providing practitioner (or intern/student complete with preceptor initial): (see Sections 22 & 23, pages 25-30);

11. The prognosis and limitations (if any) and where appropriate, any changes to the initial/ongoing prognosis during the patient treatment procedures: (see Section 18, page 21);

12. An accurate separate financial record: (see Section 27, page 33).

All of the charting entries for any patient are ultimately the responsibility of the providing practitioner. As well, the providing practitioner is also ultimately responsible for the failure to enter information.

Therefore, whether you choose to do your own charting or delegate to a staff member (including an intern or student), you must ensure that any and all information entered is accurately detailed, that no required information is absent, and that you must initial or sign each of the entries.

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9. Privacy Act Legislation

The Federal Government’s Personal Information Protection and Electronic Disclosure Act (PIPEDA), and the Alberta Government’s Personal Information Protection Act (PIPA), and Health Information Act (HIA), provide legislation that controls the use of an individual’s personal information.

These Acts require and define that businesses must safeguard an individual’s collected personal information and restrict the disclosure of that information. In Alberta, the Alberta Government’s PIPA and HIA are the legislated law which affect operations of denturists and denture clinics.

A patient attending a denturist clinic is required to be advised of these Laws and further, they must complete a PIPA Consent Form1 prior to the collection and use of their personal information by you or your clinic. It is recommended that the PIPA Consent be a separate form which will ultimately form part of the patient’s record at your office.

A patient is only required to complete this form once, unless they indicate at some future date that they wish to change the authorization of use of some of the collected information; in such a case, a new PIPA Consent Form is to be completed and specifically indicate the changes from the initial consent.

10. Confidentiality of Information

In Alberta, the HIA, PIPA and PIPEDA require that practitioners maintain patient information as confidential and that they must have consent from the patient for use of the patient’s information.

Contact with other Practitioners If in the treatment of a patient you are required to discuss the patient with any other practitioner, you require consent from that patient to do so.

It is prudent and preferable that this consent be written and obtained from the patient (or the substitute decision maker such as a legal guardian or parent). Staff Awareness All staff members must be advised of the requirements of confidentiality and the requirement of patient consent in order to release and/or transfer any patient information or patient record to any third party. Record Storage All patient records2 are to be:

Located and maintained in secured storage; In an environment such that the integrity of the record is maintained; Not distinguishably viewable by the public or other patients; Not left unattended or in public areas of the clinic; and Destroyed of appropriately and only upon expiration of the required retention period of ten

years from last date of any denturist services having been provided.

1 See sample PIPA Consent Form, Page 43 2 See Section 31, Pages 36-37

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11. Use of Symbols, Abbreviations & Terminology

If you choose to use symbols and/or abbreviations in your patient recordkeeping, these symbols/ abbreviations must be consistent throughout all patient records.

It is preferable that symbols and/or abbreviations are not used or limited in use, in order to prevent any possible misinterpretation of the recorded information.

If you do choose to use abbreviations and/or symbols, the abbreviations and symbols must be either industry accepted abbreviations/symbols (such as WNL <within normal limits>, CUD/CLD <complete upper denture, complete lower denture>, URPD <upper removable partial denture>, LRPD <lower removable partial denture>, TC <upper tissue conditioning>, TC <lower tissue conditioning>) or you must maintain and secure an easily accessible “legend” record, which fully describes your abbreviations and symbols.

As well, all symbols and abbreviations must be legible to anyone viewing the record.

The terminology used in the patient recordkeeping must be normal medical/dental terminology which is utilized by the profession.

1. Tables of Symbols & Abbreviations The following tables provide an indication of some accepted symbols and terminology abbreviations used in the medical/dental professions. Terminology Symbol Terminology Symbol

Upper or Maxillary Decrease or Less than < Lower or Mandibular Increase or Greater than > Question/questioned ? Add + Plus/Minus +/- Equal to =

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Terminology AbbreviationAbscess Absc. Abutment Abt. Acrylic Acr. Adjustment Adj. Amalgam Am. Anterior Ant. Appointment Appt. Bilateral BL Blood Pressure BP Bridge Br. Buccal Buc Cancelled Appointment C/A Cement Cem Ceramic Cm Chrome-Cobalt CC Crown Cr. Class (Classification) CL Complete Lower Denture CLD Complete Upper Denture CUD Composite Comp. Crown and Bridge C&B Deposit Dep. Diagnosis Dx Distal D Disto-vestibular DV Disto-occlusal DO Disto-buccal DB Disto-lingual DL Dorsal Dor Emergency Emerg Estimate Est. Examination Exam Extraction Ext. Free-end FE Free-end bilateral FE-BL General Anaesthetic GA Gingival Ging Gold G Gold Inlay GI Gold Onlay GO Immediate Complete Upper Denture ICUD

Immediate Complete Lower Denture ICLD

Immediate Partial Denture-Upper IURPD or PUD

Immediate Partial Denture-Lower ILRPD or IPLD

Implant Impl. Implant Crown Impl Cr. Implant retained Complete Upper Denture ImplCUD

Implant retained Complete Lower Denture ImplCLD

Impression Imp Incisal I Inferior Inf Labial La. Lingual Li.

Terminology AbbreviationMandibular Man Maxillary Max Mesio-buccal MB Mesio-distal MD Mesio-lingual ML Mesio-occlusal MO Mesio-occlusal-distal MOD New Patient NP No Charge N/C No show N/S Occlusal O or Occ Oral Hygiene Index O.H.I. Periodontal Screening & Recording PSR

Prescription Rx Pontic Pont. Porcelain fused to Gold PFG Porcelain fused to Metal PFM Post-Insertion PI Post-Insertion Check-up PI-ck Post-Operative PO Post-Operative Check-up PO-ck Post-Operative Instructions PO-inst Posterior Post. Preliminary Impressions Prelim. Preventive Home Care PHC Prophylaxis Prophy Patient Pt. Radiographs-bitewings BW Radiographs-cephalometric CEPH Radiographs- full mouth survey FMS Radiographs-occlusal OCL Radiographs- periapical PA Radiographs-panoramic PAN Recall Appointment RCAppt Received on Account ROA Referral Ref. Registration Reg. Removable Partial Denture- Upper URPD or PUD

Removable Partial Denture- Lower LRPD or PLD

Removable Partial Denture-Implant Retained Upper UIRPD

Removable Partial Denture-Implant Retained Lower LIRPD

Root Canal Therapy RCT Stainless Steel Crown SSCr. Study Model SM Superior Sup. Surgical Surg Temporary Temp. Tissue Conditioning TC Titanium Ti. Treatment Tx Vestibular V When Necessary PRN Within Normal Limits WNL Zero Balance Ø

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2. Natural Dentition Identification For the identification and charting of natural dentition, it is recommended that the International Numbering System be utilized as it does not require the use of any symbols, just simply numbers, and it is recognized throughout the world. Each tooth, whether primary dentition or permanent dentition, is designated with a specific identification via a combination of two digits. In this system, the first digit refers to the patient’s quadrant and the second digit refers to the specific tooth in that quadrant. The following two tables indicate the International Numbering System.

The combination of a quadrant and a tooth number clearly identifies the tooth as whether it is permanent or deciduous. Examples of the use of this system are:

Maxillary right permanent first molar: 1.6

Mandibular left permanent cuspid: 3.3 It is recommended that an anatomical Odontogram3 be used (drawings of each tooth, crown and root structure).

3 See sample Odontogram Form, Page 56

QUADRANTPermanent Dentition Number Primary Dentition Number Maxillary Right 1 Maxillary Right 5 Maxillary Left 2 Maxillary Left 6 Mandibular Left 3 Mandibular Left 7 Mandibular Right 4 Mandibular Right 8

TOOTH Permanent Dentition Number Primary Dentition Number Central Incisor .1 Central Incisor .1 Lateral Incisor .2 Lateral Incisor .2 Cuspid .3 Cuspid .3 First Premolar .4 First Molar .4 Second Premolar .5 Second Molar .5 First Molar .6 Second Molar .7 Third Molar .8

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12. Consent In obtaining consent for a treatment, it is essential to remember that each and every patient has the right to consider and control the decisions about their health and what treatments they wish to have, (if they are of sane mind and legally able to execute such authority).

Consent can be provided either via IMPLIED CONSENT or EXPRESSED CONSENT;

however, it must always be INFORMED CONSENT.

Consent is not just providing the patient with a document for them to read and sign. Consent requires that you discuss the proposed treatment plan with the patient, so that they can make an informed decision regarding their health care needs and treatments. 1. Implied Consent

Implied Consent is consent by the patient’s actions or words, such as when a patient voluntarily attends the clinic for treatment and is fully aware and fully understands what is being done or will be done, that they can object to what is being done at any time, and finally, that they allow themselves to be treated. 2. Expressed Consent

Expressed Consent is clear and unequivocal consent provided to you by the patient, whether verbal or in writing, for you to provide the treatment. For example, a patient stating to you “You can fit me with new top and bottom dentures”, or providing a written and signed consent to a specific treatment plan, is expressed consent. 3. Informed Consent

Informed Consent is where a patient has been specifically informed about all aspects of the recommended treatment, that a reasonable person in the same circumstances would want to know, including the estimated costs, and that they have agreed to proceed with the treatment (either by implied or expressed consent). In order for consent to be valid, the patient must provide you with an informed consent voluntarily, to the specific procedures indicated in an accepted recommended treatment plan. With cases involving complex/lengthy treatment plans, major services, where there are known risks, referrals to other practitioners, refusals of recommended treatment(s) or referral(s), unrealistic expectations by the patient for treatment outcomes, it becomes essential that written expressed consent be obtained prior to initiating the treatment.

Continued on page 11

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In order for a patient to be able to provide informed consent, several items must be explained to the patient in terms which can be understood by the patient.

These items include but are not limited to:

i. The diagnosis; ii. All viable treatment options including no treatment; iii. Recommended treatment and the justification for the recommended treatment; iv. Initial prognosis including indication of the expected outcome/success of the recommended

treatment and for no treatment; v. Materials to be used; vi. Unusual risks or possible complications associated with the recommended treatment; vii. Fees related to the recommended treatment and where applicable, the anticipated portion

covered by third party insurance; viii. Financial terms and agreements; and ix. Recommended referrals to other practitioners.

It must be noted that a “general coverall consent” which can be found on many commercially available charts, does not fulfill the requirements of a specific informed consent for a specific treatment nor does it provide you with expressed consent.

As such and where appropriate, a detailed expressed consent for specific treatment(s) which has been fully discussed with the patient (or responsible individual), and fully documented, should be obtained and maintained in the patient’s record.

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4. Consent of Dependent Adult Patients

An adult patient is any individual who eighteen (18) years of age of older.

An adult patient, who cannot continuously look after themselves, or has a mental disability, or are otherwise unable to make reasonable decisions regarding their health care, will usually be under the control of a Legal Guardian.

In treating patients of this category, it is essential to determine who has the legal guardianship of the patient, as you must obtain consent to treatment from that guardian prior to providing any services to a the patient. This consent of course, should be in writing.

The Alberta Dependent Adults Act4 became law in 1980. This law has rules for determining who can be appointed as the legal guardian of a dependent adult and further, defines what power and authority the guardian will have with respect to matters of the dependent adult.

Section 1 of the Act defines a “dependent adult” as:

(e) “dependent adult” means a person in respect of whom:

(i) A guardianship order is in effect, (ii) A trusteeship order is in effect, or (iii) Both a guardianship order and a trusteeship order are in effect.

Section 19 of the Act states:

“A Guardian shall exercise Guardian’s power and authority: (a) in the best interests of the Dependent Adult; (b) in such a way as to encourage the Dependent Adult to become capable of caring for

himself and of making reasonable judgements in respect of matters relating to his or her person; and

(c) in the least restrictive manner possible.

If a patient in this category attends your clinic with an individual who expresses that they are the legal guardian of that patient, but does not have documentation to provide you with indicating such or if you are unsure or it is not clear that the adult who is accompanying the patient is in fact a legal guardian of that individual, then you must take additional steps to determine the guardianship prior to providing any treatment.

A prudent practitioner will ensure that they are confident that the accompanying adult is in fact the legal guarding of the patient, prior to providing any services.

For additional information, the Dependent Adults Act can be viewed at the Queen’s Printer website at:

http://www.qp.gov.ab.ca/documents/Acts/D11.cfm?frm_isbn=0779752430

4 See Queen’s Printer Website: http://www.qp.gov.ab.ca/documents/Acts/D11.cfm?frm_isbn=9780779723799

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5. Consent for Minor Aged Patients A minor aged patient is any individual who is less than eighteen (18) years of age. In treating patients of this category, it is essential to determine who has the guardianship of the minor aged patient, as you must obtain consent from the guardian prior to providing any services to a minor aged patient. This consent of course, should be in writing. The Alberta Family Law Act5 became law in October of 2005. This law has created new rules for determining who the legal guardian of a minor aged individual is. Usually minor aged patients attending a denturist clinic will be attending with one or both of that child’s parents. It is reasonable for a practitioner to make the assumption that the parent or parents are the legal guardian of the child. However, if you are unsure or it is not clear that the adult accompanying the child is in fact a legal guardian of that child, then you must take additional steps to determine the guardianship prior to providing any treatment. The following table provides a guideline of procedure to assess guardianship. A prudent practitioner will ensure that they are confident that the accompanying adult is in fact a legal guarding of the minor aged patient, prior to providing any services.

5 See Queen’s Printer Website: http://www.qp.gov.ab.ca/documents/Acts/F04P5.cfm?frm_isbn=0779740718

Accompanying Adult is: Guardianship is by: Suggestions for Additional Inquiry/Verification

Natural Mother and/or

Natural Father

Natural parent which provides a very strong possibility of guardianship.

• Review Section 20 of the Family Law Act, Schedule “A”, to determine if the individual fits into one of the categories. (see queens printer website at:www.qp.gov.ab.ca/documents/Acts/F04P5.cfm?frm_isbn=0779740718

Divorced Mother Guardian unless removed by a Court Order.

• Does the mother have sole custody or is there joint custody of the child?

• If sole custody, does the non-custodial father have right of access to this patient’s records?

• Review a copy of the Court Order.

Divorced Father Guardian unless removed by a Court Order.

• Does the father have sole custody or is there joint custody of the child?

• If sole custody, does the non-custodial mother have right of access to this patient’s records?

• Review a copy of the Court Order. Adoptive Mother Guardian by Court Order. • Review a copy of the Court Order. Adoptive Father Guardian by Court Order. • Review a copy of the Court Order.

Non-parent adult: • Stepparent • Foster parent

No rights of guardianship unless by Court Order, appointment under will, agreement or temporary agreement.

• Review copy of the Court Order, or the Will, Grant of Probate, or the agreement/appointment.

Child Welfare Authority

No rights of guardianship unless by Court Order, appointment under will, agreement or temporary agreement.

• Review copy of the Court Order, or the Will, Grant of Probate, or the agreement/appointment.

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13. Patient Signatures

To ensure as much accuracy as possible in the patient record, it is prudent to obtain the patient’s signature on the patient record for significant matters.

This would include, but is not limited to, the following:

1. Medical histories complete with the date, and on the periodically completed medical history updates.

2. Dental histories complete with the date, and on the periodically completed dental history updates.

3. Consent to treatment. 4. Consent to the fees for the treatment. 5. Instructions provided for major procedures/treatments. 6. Any financial arrangements. 7. Consent to obtain and/or release patient information (as per law such as PIPA), including

for the transfer of a copy of the patient record to another practitioner. 8. Any refusal of recommended treatments and/or recommended referrals to other

practitioners.

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14. The General Patient Information Requirements

For each and every patient, the personal information section6 of the patient record, (which is completed by the patient and/or guardian or clinic staff member), must contain the following information and be updated at regular intervals upon the patient’s return to your office or upon notification by the patient of a change to their information:

• Full Legal Name; • Date of birth; • Gender; • Home and mailing address; • Home and work telephone numbers; • Email addresses; • Name and telephone number of patient’s family physician; • Name and telephone number of patient’s family dentist; • Name and telephone number of previous denturist (if applicable): • Name and telephone number of referring health care provider (if applicable); • Legal Guardian/responsible individual (if applicable); • Emergency contact name and phone number(s); • Name of the individual or agency responsible for patient account; and • Dental Insurance information7 (if applicable).

6 See sample Personal Information Form, Page 44 7 See sample Dental Insurance Company Information Form, Page 61

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15. The Medical History Information Requirements

The medical history obtained at the initial appointment, is to be reviewed with the patient and initialled by the attending denturist and further, this medical history (which is completed by the patient and/or guardian or clinic staff member), must be signed by the patient or, if applicable, the responsible individual.

There are several goals in obtaining an accurate medical history:

• To identify any significant medical condition(s) and/or drug interactions/side effects, so that you can determine whether or not there are any risks in treating the patient at that time;

• To provide indication of a patient’s level of stress which may affect the treatment processes and how the treatment is provided to that patient;&

• To determine if the treatment can be provided safely.

The medical history must be updated at regular intervals8; once per calendar year (if the patient attends annually), or upon the patient’s return to your office after one year, or upon notification by the patient of any change to their information. This updating is to be date recorded and signed. Further, any changes are to be reviewed by the denturist with the patient and both the denturist and the patient must sign or initial the changes. In order to provide safe services to a patient, all necessary and relevant medical information is required.

The collection of the medical history information should be done in a systematic manner. Most commercially available medical history forms and those incorporated into dental computer software programs, are fairly systematic. Any indicated conditions which are or may be pertinent to the treatment being provided, must be conspicuously noted in the chart. It is essential that there be sufficient room for the recording, updating and appropriate signatories for the relevant collected information, and that the responsorial areas are in a format of positive/negative via yes/no. Upon a patient’s completion of the medical history form, the responses must be discussed by the denturist with the patient and any necessary notes charted and signed or initialled by the practitioner.

It is imperative that any conditions pertinent to the patient’s care, are conspicuously noted in the patient record.


8 See sample History Update Form, Page 49

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The following provides a general indication as to a systematic record of a health history.

⌦ Significant respiratory disease such as asthma, emphysema, Chronic Obstructive Pulmonary Disease (COPD), tuberculosis, etc.

⌦ Known allergies.

⌦ Unusual or adverse reactions to oral or injected medication such as penicillin, aspirin or local anaesthetics.

⌦ Heart disease or heart attack, high or low blood pressure, or strokes.

⌦ Heart murmur or mitral valve prolapse.

⌦ Rheumatic fever.

⌦ Epilepsy or seizures.

⌦ Blood disorders (such as haemophilia).

⌦ Bruising tendency.

⌦ Endocrine disorders such as diabetes.

⌦ Cancer and treatment received such as radiation and or chemotherapy.

⌦ Hepatitis A/B/C, jaundice and or liver disease.

⌦ Gastrointestinal disorders.

⌦ Kidney disease.

⌦ Immuno-compromising disease such as HIV/AIDS.

⌦ Eating disorders such as anorexia nervosa or bulimia.

⌦ Any prosthetic joints such as hip or knee.

⌦ Pregnancy.

⌦ Psychiatric disorders and treatments.

⌦ Drug and or alcohol dependency.

⌦ Any other conditions, problems or treatments which the practitioner should be aware of.

⌦ Any medications prescribed for any conditions.

A certification and consent must accompany the medical and dental histories in a form such as:

“I the undersigned, hereby certify that all of the medical and dental information provided on

this form to be true to the best of my knowledge and that I have not knowingly omitted any

information. I also consent to my family physician/dentist being contacted, if necessary, to

obtain further information or clarification of medical/dental conditions as is necessary for

treatment provided by my denturist.”

Dated this ____ day of __________, 20___.

______________________________________ Patient Signature

The medical history form9 and the dental history form can be combined into one form.

9 See sample Medical History Form, Pages 45 - 46

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16. The Dental History Information Requirements

The patient’s dental history supplements the findings of the examination by the denturist, which in turn, will assist in the diagnosis and formulation of appropriate treatment plans and a prognosis for treatment. The goals of obtaining a complete dental history include: • Provides additional information for consideration with the findings of the denturist’s

examination; • Provides additional information for consideration in treatment planning; • Provides information on the patient’s previous dental experiences, successes and/or

problems; • Provides indication of the patient’s level of concern of their oral health.

Where applicable, the dental history (which is completed by the patient and/or guardian or clinic staff member), must be updated at regular intervals10; once per calendar year (if the patient attends annually), or upon the patient’s return to your office after one year, or upon notification by the patient of any change to their information. Most commercially available dental history forms are not directed towards patients requiring or having dental prosthetics, but rather to a patient with natural dentition. Therefore, denturists need to have a dental history form which is applicable to patients who have or require dental prosthetics.

The following is a minimal checklist for the patient’s dental history: ⌦ Date of last dental/denturist visit. ⌦ The purpose of the last dental/denturist visit. ⌦ Any dental radiographs within the last two years. ⌦ Any ongoing dental procedures. ⌦ What type of dental prosthesis they have (if applicable). ⌦ Age of the current dental prosthesis (if applicable). ⌦ How often they brush their natural teeth (if applicable). ⌦ How often they floss their natural teeth (if applicable). ⌦ Whether or not their gums bleed around their natural teeth when they brush (if applicable). ⌦ Whether or not they brush their gums under the prosthesis (if applicable). ⌦ Whether or not they wear their prosthesis at night (if applicable). ⌦ Whether or not they have been in an accident and experienced any trauma and/or damage the jaws

and/or temporomandibular joint complex. ⌦ Any pain/numbness in the head, neck or jaws. ⌦ Whether or not they have had any dental implant surgery. ⌦ Any anomalies or sore spots. ⌦ Difficulties in chewing food. ⌦ Habitual conditions such as mouth breather, chew on foreign objects, etc. ⌦ A list of any other dental related matter which has not been addressed above.

Again, the medical history form and the dental history form11 can be combined into one form.

10 See sample History Update Form, Page 49 11 See sample Dental History Form, Pages 47 - 48

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17. Clinical Examination

The patient record must contain a clinical examination chart with the recording by the practitioner (or staff member recording on instruction from the practitioner), of the conditions which were present on the initial clinical examination of the patient. The initial record of these findings should remain as unaltered.

The information is broken down into the following categories and the minimal items to evaluate (where applicable):

1. Extraoral Examination • general physical appearance • head • lips

• neck • lymph nodes - lumps/masses • vital signs

2. Temporomandibular Joint Complex

• jaw joint and/or masticatory muscle tenderness or soreness

• range of vertical jaw opening

• range of lateral jaw movement • presence of clicking and/or crepitis

3. Intraoral Examination

• mucosa • ridge classification (A-E) • residual ridge conditions • tori (if present) • tongue

• floor of mouth • pharynx and tonsils • saliva • soft palate • lateral throat form

4. Prosthesis Evaluation

• centric relation and centric occlusion • interocclusal distance • lateral excursions • protrusive excursions

• classification of jaw relationship • prosthesis condition including the base,

teeth, frameworks, etc.

5. Dentition & Periodontal Evaluation • status of dentition & missing dentition • oral hygiene • bleeding and/or exudates • mucosa condition • tooth mobility measurement

• periodontal screening record or probing record (if applicable)

• tissue color, position, shape, texture & consistency.

6. Radiographic Evaluation

• If applicable, any radiographic findings.

The Clinical examination forms 12 collectively form part of the patient record.

12 See sample Forms, Pages 50-57

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18. Diagnosis, Treatment Plan & Prognosis

The approach for treatment of a prosthodontic patient occurs in two areas which are composed of four phases:

1. The Diagnosis: i. The identification of the disease or diseases present.

2. The Treatment Plan and provision thereof: i. The removal of the disease process or processes;

ii. The restoration of stomatognathic function and aesthetics; &

iii. The monitoring and maintenance of the patient’s general oral health. A. DIAGNOSIS

The diagnosis is formulated from the objective information from the clinical examination, the patient’s dental and medical histories, and the results of any diagnostic aids such as study models or radiographs and/or reports from other healthcare providers, and is supplemented by the subjective information provided by the patient such as the expressed chief complaint(s). The examination reveals the signs and symptoms and the diagnosis is the practitioner’s professional opinion of the cause of the symptoms (the disease).

The diagnosis must be recorded in the patient chart by the practitioner (or staff member recording on instruction from the practitioner), in the progress notes section.

B. TREATMENT PLAN

The treatment plan should be based on the information gathered from the diagnosis. It must be recorded in the patient record by the practitioner (or staff member recording on instruction from the practitioner), in the progress notes section and it must list the services to be performed for that patient. The proposed treatment should be based on the following criteria wherever possible:

1. The removal of the identified disease or diseases present. 2. The achievement and maintenance of aesthetics and phonetics. 3. The achievement and maintenance of maximal dental/oral health for the patient in their

particular set of circumstances. 4. The prevention of recurrent disease or malocclusion and/or future degenerative changes to

the stomatognathic system.

Treatment plans should take into consideration the severity and urgency of the patient’s conditions and be supportable with clinical findings and accurate records. As well, treatment alternatives must be discussed and reviewed with the patient and duly recorded.


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A treatment Plan Options form13 can provide a consistent method for creating the recommended treatment plans, and ensure that the proposed treatment(s) will in fact, address the issues and needs of the particular patient and the professional obligations of the practitioner.

Treatment plans and the fees quoted to the patient for the treatment must be directly correlated.

For extensive treatment plans, the following should also be recorded: 1. A schedule of the appointments. 2. A timeline for the treatment from initial date to completion. 3. A brief description of the services to be provided at each appointment. If applicable, any

condition(s) which are being monitored and further, that the patient has been made aware of the condition(s) being monitored.

The treatment plan form can be a separate form or document which ultimately forms a part of the patient record. Some practitioners may choose to record the recommended treatment plans and the consented to treatment plan, into the progress notes section of a patient chart, and some may choose to have it separated; however, both must be recorded. With an extensive consented to treatment plan where there will be numerous appointments, referrals, surgeries, and post-delivery follow-up for an extended period of time, it is recommended that the treatment plan be a separate document with signed expressed consent, and it must be retained in the patient record.

Generally speaking, the more involved the treatment plan is - the more information which must be provided to the patient. Further, the use of separate treatment plan forms or documents, allows for easy provision of a copy of the treatment plan(s) for the patient to retain.

C. PROGNOSIS

A prognosis is a statement of the practitioner’s professional opinion as to the success of the treatment which has been provided to a patient, with consideration not only the patient’s anatomical and physical considerations, but also the patient’s psychological acceptance and expectations of the treatment. An initial prognosis must be recorded prior to initiation of treatment and a final prognosis must also be recorded upon completion of the treatment plan; both of these in the progress notes section by the practitioner (or staff member recording on instruction from the practitioner). A prognosis is described in one of the following four terms: Excellent: The patient will be successful with the provided treatment (no concerns).

Good: The patient should be reasonably successful with the provided treatment (some concerns).

Guarded: The patient will most likely have some difficulty with the provided treatment but may overcome the difficulties with time.

Poor: The patient will have difficulty with the treatment indefinitely. Further, each prognosis must be discussed and reviewed with the patient and appropriately recorded in the progress notes.

13 See sample Treatment Plan Options Form, Page 59-60

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19. Personal Comments

Practitioners can add personal comments regarding the patient and/or their families. Such entries can aid the staff in communicating on a more personal level, as well as serving as a reminder to the practitioner for future patient visits.

However, all personal comments must be discreet, accurate and relevant to the care which is being provided to, or will be provided to, the patient.

Be reminded that patients have the right to request to review or to obtain a copy of their record, which includes the personal comments recorded in the record.

20. Information Presented to the Patient

Information presented to a patient is to be documented in the patient record in the progress notes section, and where appropriate, a copy provided to the patient.

When the treatment plan is complex, a comprehensive discussion with the patient is recommended, which would include discussion of the:

Diagnosis- arrived at from the patient examination(s) and tests; Alternate treatment plans; Risks of the treatment; Probable risks of not completing the treatment; and Prognosis associated with each proposed treatment.

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21. Choice of Patient Chart

The choice of a “type” of patient chart and the recording methodology is solely the practitioner’s. Regardless of the type, it is essential that there is adequate space to record all relevant information at initial examination as well as ongoing procedures, changes and updates whenever necessary.

As well, the ability to easily add pages as necessary to a patient record is highly recommended. Multiple treatments to a patient will require additional space for appropriate recordkeeping and as such, a consistent methodology is necessary.

1. Extraoral Examination

The patient chart must contain an extraoral examination form. This form should be systematically organized and in a form which provides for entering notes on the findings. All entries must be permanent. As well, any future changes to initial findings must be indicated after the initial findings, dated and signed/initialled by the denturist. It is recommended that the initial record remain unaltered. The extraoral and intraoral examination forms can be combined into one form.

An example of an extraoral form is located on page 50.

2. Intraoral Examination

The patient chart must contain an intraoral examination form. This form should be systematically organized and in a form which provides for entering notes on the findings.

All entries must be permanent. As well, any future changes to the initial findings must be indicated after the initial findings, dated and signed/initialled by the denturist.

It is recommended that the initial record remain unaltered. The intraoral and extraoral examination forms can be combined into one form.

Any example of an intraoral form is located on page 51-53.

3. Odontogram

The patient chart for patients with natural dentition must contain an odontogram which is large enough to allow for the appropriate charting of all pertinent clinical findings.

The choice of the type of odontogram to use is solely the practitioners; however, one type should be used for all patients for consistency purposes. The College recommends an anatomical Odontogram.

Further, the initial visit odontogram is to remain unaltered.

Subsequent patient visits and changes to the status of the dentition should be charted on a separate odontogram or recorded in writing in a different colour, in the patient records. Example of an odontogram is located on page 56.


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4. Radiographs

Practitioners must use their professional judgement in the prescribing of radiographs as to the necessity and validity of such a prescription.

The number, type and frequency of the radiographs, is to be founded on an individual patient basis with consideration to the patient’s clinical signs, symptoms and past dental history.

As well, an appropriate referral must be used and a copy of that referral must be retained on the patient’s record.

Radiographs form an important part of the patient record and as such, they need to be of acceptable diagnostic quality, be clearly labelled and dated.

With digital radiography, a digital record must be maintained of the original exposure (unaltered) and any additional program enhanced views also maintained.

Additionally, it is recommended that a hard copy of the patient’s digital radiographs be maintained, such as a DVD or CD. An example of a radiograph referral slip is located on page 71.

5. Periodontal Screening Record & Tooth Mobility Measurement Record

When appropriate and applicable, a periodontal screening & record (PSR) and tooth mobility measurement record is to be incorporated into a patient’s record.

Such records can be made by the attending denturist if they are adequately trained to conduct periodontal screenings and tooth mobility measurements. Otherwise, with the consent of the patient, a copy of the record from the patient’s dentist or hygienist should be obtained.

These records are to be recorded permanently, updated periodically, (once per calendar year or upon their return to your office) and with a new periodontal screening performed and recorded onto a new PSR report form. It is essential that the original record be maintained unaltered. An example of a periodontal screening report and tooth mobility measurement record is located on page 57.

6. Partial Denture Prescriptions

Partial Denture Prescriptions must be recorded permanently and on a separate form; either via a laboratory prescription pad, or a practitioner’s own prescription form.

An example of partial denture prescription forms are located on page 62.

7. Financial Ledger

The financial matters pertaining to a patient must be recorded permanently and on a separate form such as a financial ledger and it is prudent to have a financial terms agreement form.

As well, copies of insurance claim submissions, statements or other matters related to the financial aspects of a patient’s treatment must be retained with the record. An example of a financial ledger is located on page 63 and financial terms agreement form on page 63.

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22. Progress Notes

The progress notes are a required descriptive record of the progression of treatment both “what happened clinically at the appointment or interaction” as well as “any related technical events” that require documentation. The progress notes generally include:

• The patient’s subjective information;

• The practitioner’s objective assessment/analysis;

• The treatment provided to the patient;

• The prognosis;

• Future processes to be completed; and

• Who the providing practitioner is. Every appointment that a patient attends your clinic or where you provide services to a patient at a location out of your clinic, (such as at a private residence, nursing home or hospital), as well as any correspondence which relates to that patient which you receive, requires an entry of this interaction, into the patient’s progress notes by the practitioner (or staff member recording on instruction from the practitioner). These entries are to be done on the same day, (immediately if possible), upon completion of the appointment or upon the completion of the review of the received correspondence. As well, if any limitations of the treatment(s) are discussed with the patient, this must also be recorded.

A. Entering Information into the Patient Record

As the patient record is a legal document regardless of method used for recording the information, it is essential to prevent the possibility of misinterpretation of the entered information that all entries consistently exhibit:

Legibility: clean, printed entries in pen only (unless utilizing a computer program) with proper spelling, grammar and punctuation.

Consistency: entries must be organized using a systematic methodology.

Accuracy: truthful, without assumptions and unexaggerated objective information.

Brevity: short, succinct sentences with the information stated concisely.

Clarity: the meaning of any entry should be immediately clear to any reader (dental terminology and abbreviations notwithstanding).

Chronology: entries must be dated and recorded in the order they occurred.

Signature: each entry is signed by the providing practitioner, (or intern/student if applicable, with practitioner initialling also), including electronic records via digital signatures.


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The use of recognized symbols/abbreviations14 can assist in providing brevity and clarity to the entries; however, their use should be limited in order to prevent possible misinterpretation of the entered information. With a computer software program recordkeeping system15, it is helpful to have a program which contains a spelling and grammar check and a dictionary which can be customized and continuously added to. Further, computer software programs must allow the user to place digital signatures onto each entry, as this is a requirement. B. Entering Personal Comments into the Patient Record

As the patient record is a legal document regardless of method used for recording the information, a practitioner’s personal comments must meet the criteria on personal comments16.

To ensure accuracy and validity, Progress Note entries are to be done

on the same day, (immediately if possible), upon completion of the appointment/interaction, or upon the completion of the review of

the received correspondence.

14 See Section 11, Pages 7 - 9 15 See Section 26, Page 32 16 See Section 19, Page 22

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23. Progress Notes Method Although the style and content of progress notes will vary from practitioner to practitioner, it is essential that the information meet the criteria as described in Section 22.

Progress notes are a required descriptive record of the progression of treatment both “what happened clinically at the appointment or interaction” as well as “any related technical events” that require documentation.

A. Multiple Appointment Procedures

When a patient is attending for a multiple appointment procedure treatment such as new dentures, then the progress notes are broken down into three main note “types” as follows:

1. Initial Note 2. Ongoing Treatment Note 3. Final Treatment Note

1. Initial Note The initial note is entered during and/or upon completion of the initial appointment with the patient, whether this is a consultation appointment, examination appointment, or combination of multiple different procedures. This note will include the following information (where applicable):

Patient’s reason for attendance (chief complaint or complaints). Findings of the examination (separate from the actual examination recordings). Examples:

Examination findings WNL (within normal limits); or: Examination shows suspicious tissue presentation in floor of mouth.

Recommended treatment, if any, for examination findings. Examples: Will tissue condition upper and lower to heal tissue; or: Referral to Oral Surgeon for analysis of tissue; or similar such procedures.

Synopsis of recommended treatment plans (separate from actual recommended treatment plans form) with justification and limitations indicated. For example: Suggest new complete dentures due to current dentures being ill-fitting, malocclused and overclosed; or similar such information.

Indication (brief summary) of the patient’s consented to treatment (separate from actual signed consent to treatment form). For example: Patient consented to new dentures as per consent form.

Description of what was done at the appointment. For example: Consultation and general examination; or: Preliminary impressions; or similar such procedures.

Specifics related to any treatments provided (added to initial description of what was done at the appointment). Examples, tissue conditioning to upper and lower dentures with XYZ Brand, or: preliminary impressions done- trays U22 L24, or similar such procedures.

Statement of initial prognosis- Excellent, Good, Guarded or Poor. Note on procedures for next appointment. Examples: Will do preliminary impressions at next

appointment; or: Will do secondary impressions at next appointment.


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2. Ongoing Treatment Note

The ongoing treatment note is entered during and/or upon completion of each and every appointment in a series of treatments for the patient. This note will include the following information (where applicable):

Description of what was done at the appointment. Examples: Adjust tissue conditionings; or: Secondary impressions done; or similar such procedures.

Specifics related to any treatments provided (added to initial description of what was done at the appointment). Examples: Adjust tissue conditionings and polish- tissue healing well; or: Preliminary impressions done- trays U22 L24; or: Secondary impressions taken with XYZ Brand; or similar such procedures.

Any change to initial/ongoing prognosis. For example: Patient now more accepting of having new dentures, prognosis upgraded to Excellent.

Note on procedures for next appointment. Examples: Will do secondary impressions at next appointment; or: Will do pin-tracing and facebow transfer at next appointment.

3. Final Treatment Note

The final treatment note is entered during and/or upon completion of the final appointment in a series of treatments for the patient. This note will include the following information (where applicable):

Description of what was done at the appointment. Examples: Insert Complete Upper and Lower Dentures; or: Post-Insertion check-up; or: Remount and equilibration completed.

Specifics related to any treatments provided (added to initial description of what was done at the appointment). For example: Insert Complete Upper and Lower Dentures. Used pressure paste to check and refine fit.

Final Prognosis. Examples: Patient very accepting of new dentures, prognosis remains Excellent; or: Patient still uncomfortable with loosing natural teeth and having dentures - prognosis remains Guarded.

Note on procedures for future appointment. Examples: Patient does not want a post-insertion appointment, patient will call if having any problems (or you can use the abbreviation of PRN); or: Post-insertion check-up - minor adjustment to mandibular left labial frenum - otherwise, doing well - PRN; or: All okay, will recall in one year, PRN; or: Book appointment for six months to assess resorption from extraction of tooth ##, PRN or similar such procedures.


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B. Single Appointment Procedures

When a patient is attending for a single appointment procedure treatment such as an adjustment or a repair, then the patient care notes are broken down into two entries as follows:

1. Initial Note 2. Final Note

1. Initial Note

The initial entry is done at the start of the appointment/procedure, and will indicate what treatment is to be provided. This note will include the following information (where applicable):

Patient’s reason for attendance (chief complaint or complaints). Practitioner’s initial diagnosis. Description of what is to be done at the appointment. Examples: Repair fractured complete

upper denture; or: Impression for Upper Complete Denture Reline; or: Adjustment of Complete Lower Denture; or similar such procedures.

2. Final Note

The completion entry is done at the end of the appointment/procedure, and will indicate what treatment was provided. This note will include the following information (where applicable):

Specifics related to any treatments provided (added to initial entry). Examples: repair fractured complete upper denture - model required – strengthening wire placed – denture inserted, minor adjustment to rugae area; or: Impression for Upper Complete Denture Reline with XYZ Brand – processed reline inserted., minor adjustment to labial frenum; or: Adjust Complete Lower Denture lingual flange - overextended; or similar such procedures.

Prognosis. For example: Guarded as repair is only a temporary solution. Note on recommendations. For example: Suggest consider upper reline to strengthen

denture, PRN; or: Suggest consider consultation and examination regarding replacing dentures, PRN; or similar such information.


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C. Sample of Patient Care Notes Entries

The following provides an example of entries of the Progress Notes17 method.

Date

DD-MM-YY

Notes

Signature\Initial of Practitioner

01-22-XX Initial consultation and general prosthetic examination. Oral conditions WNL except for severely resorbed mandibular residual ridge. Case is overclosed, teeth worn and is now in an acquired prognathic bite, limited anteriors showing even when speaking. Both dentures are ill-fitting. Discussed options: 1- do nothing; 2- replace with equilibrated CUD & CLD; 3-referral for implant assessment. Prognosis is Good. Patient will consider and advise- PRN.

AB

02-12-0XX Secondary consult- wishes to investigate feasibility of implants- referred to Dr. D. Implant, on 02-14-06 @ 1430. Adj. mand. Left crest about 44-45 region. Booked next appt. 02-18-06, 02-21-06. AB

Patient will likely do okay with implants, but is concerned with the expense. well AB

Follow-up appt. here booked. PRN.

AB

02-21-XX Patient has chosen not to have implant treatment; wishes only new equilibrated CUD-CLD. Will provide equilibrated U&L; increase OVD~ 3 mm, + incisal length of anteriors, non-interceptive occlusal scheme for increased stability. Financial agreement completed and signed. Consent to treatment form not AB signed. Prelims with alginate, stock trays U22, L21. Next appt- final imps. PRN.

AB

02-27-XX Patient called; is ill – appt. cancelled. Rescheduled to 03-03-06 ZZ 03-03-XX Mucosa is free of anomalies. Final Imps in custom trays, XXXX material upper,

XX material lower. Next appt: registration & facebow transfer. PRN. AB

03-09-XX Registration done- pin tracing and facebow transfer. Old Freeway Space 08 mm New Freeway Space 03 MM Tooth selection done; patient wishes white AB same size and shape of anterior teeth but whiter teeth; selected shade 1. Difficult tracing but definite arrowhead revealed. Next appt; full wax try-in. Patient to bring in spouse to view. PRN.

AB

03-17-XX Patient nervous today. Try-in with spouse. Centric occlusion at centric relation; OVD appears good with about 1mm closest speaking space. Esthetics and technical aspects acceptable. Next appt: insertion of new dentures. PRN.

AB

03-27-XX Insert dentures- minor adjustment to lower lingual flange extension. Centric occlusion and centric relation in harmony, protrusive and lateral excursions good. Prognosis remains Good. Booked for equilibration in one week. PRN.

AB

04-03-XX Patient doing very well. Remount and equilibration done- minor lateral interferences. Re-insert. Prognosis now Excellent. PRN. Book recall in one-year.

AB

Reminder: “PRN” is the abbreviation utilized which indicates a patient is responsible to contact

the practitioner when necessary.

17 See sample Progress Notes Form, page 58.

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24. Documenting Referrals

Any referral to another health care provider must be appropriately recorded in the progress notes by the practitioner (or staff member recording on instruction from the practitioner). As well, any copies of referral letters, reports and correspondence received from the referred to practitioner, must be retained within the patient record.

Any conversations with other providers regarding the patient must also be duly recorded into the progress notes in the patient record.

Be reminded that you must obtain patient consent prior to discussing the patient’s condition with any other practitioner/third party and this consent should be recorded into the chart (PIPA consent).

Additionally, it is prudent to have a signed consent obtained and retained in the patient record (whenever possible).

Finally, if you have recommended a referral and the patient refuses the referral, it is pertinent that you record this refusal and whenever possible, have the patient sign the charting entry indicating their refusal of the referral. Examples of referral sheets are located in Section 36 on page 68-71.

25. Recall (Continued Care)

It is recommended that all practitioners adopt a systematic methodology of patient notification, (upon completion of treatment), for necessary post-insertion treatment checkups and general treatment follow-up (recall).

Practitioners are to enter into the chart the recommended date for the patient to be recalled and for what purpose. Additionally, records of missed or cancelled recall appointments are to be appropriately recorded in the progress notes in the patient record.

When a patient attends for a recall appointment, it is prudent to have a set methodology for the Continued Care Appointment. Further, the charting must reflect this appointment and that the following are recorded by the practitioner (or staff member recording on instruction from the practitioner):

1. Updating of Medical & Dental Histories18 by the patient, complete with patient signatures and with notation and signature/initial of the attending denturist (or if applicable, the intern/student with practitioner’s initial) and that the updated medical and dental histories were reviewed with the patient.

2. The type of examination to be provided and findings.

18 See Medical/Dental History Update Form, Page 49

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26. Electronic Recordkeeping Electronic computer recordkeeping is a viable and approved method of patient recordkeeping. It must be noted however, that electronic records must comply with the same requirements of the traditional paper recordkeeping.

In this day and age, there are numerous software programs available to practitioners, which offer a variety of functions and provide for a comprehensive patient record.

For an electronic computer recordkeeping program to be acceptable, the program must contain the following minimum requirements:

1. That there is an accurate visual display of the information recorded. 2. That the information recorded can be retrieved and printed. 3. That original entered information is unalterable (within a short time period of the entering the

information) and that there is a continuous audit trail which: Indicates any changes to the recorded information; Maintains an original content record when information is changed, updated or deleted; Date records each entry for each patient for clinical entries; Date records each entry for each patient for financial entries; and

4. Reveals the digital signature of individual who made the entries. 5. That there is access to each patient’s clinical and financial records by patient name. 6. That there is the capability to visually display and print clinical and financial information for

each patient in a chronological order, for a specified date and/or period of time. 7. That the program is password protected or has some form of unauthorized access

prevention. 8. That the program contains a backup method to a removable recording media, has a method

for data recovery, protection against loss, damage, corruption and/or inaccessibility to any or all patient information.

It is prudent to perform a daily backup of the records and remove a copy of the backup from the premises, and that you ensure that all necessary steps are taken to maintain security of the copy and the information contained therein. Further, it is recommended that a hard copy of the data is maintained in a systematic chronological manner.

Practitioners must take necessary steps to ensure the safeguarding of all of the computer equipment from electrical failures or fluctuations (surges), theft, fire, water damage or any other hazard, wherever possible.

Access to the computers must be restricted to only those authorized individuals, and the use of screen savers, passwords, etc., is to be utilized.

Prevention of the viewing of the computer screen by patients or the public is required to ensure safeguarding of confidential information.

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27. Financial Records

Financial arrangements, invoicing, payments, etc., form an important and integral part of the patient record. The patient record must indicate financial arrangements and agreements with the patient, as well as provide indication as to who is responsible for the financial matters. In the case of an agreement on financial matters, a separate written and signed financial terms agreement form19 should be completed and retained in the patient record.

Financial records are not to be contained in patient care notes. A financial record must be a separate form20 (such as a ledger) which forms part of the patient record.

The financial record for each patient must contain:

1. A copy of any written financial agreements with the patient. 2. The dates of services, procedures and/or codes and the amounts of all fees charged. 3. The dates, amounts and method of all payments made. 4. An itemized list of external invoicing such as commercial laboratory fees. 5. Copies of all dental insurance claim forms, from current to the preceding ten years. 6. Signature/initial of the individual whom made the entry into the financial record.

The following is an example of a financial record “ledger” with entries:

Patient Name: Financial Record Date Procedure Code Amount Balance Signature

01-22-XX Consult/general exam, Bill insurance 01701 XX. XX XX.XX ZZ

01-29-XX ROA Insurance XX.XX Ø ZZ

02-20-XX External : YY Dental Lab- Ti Palate XXX.XX XXX.XX ZZ

02-22-XX External : Payment to YY Dental Lab- our cheque #1234 XXX.XX Ø ZZ

03-03-XX

ROA- Patient deposit VISA, for Equilibrated CUD with cast Ti palate &CLD Balance To be billed to insurance

5120151202

XXX.XX <XXX.XX> ZZ

04-05-XX Equilibrated CUD & CLD- bill to insurance

5120151202

XXXX.XX XXX.XX EF

05-05-XX ROA- Insurance XXX.XX XX.XX EF

05-05-XX Statement issued to patient XX.XX EF

05-12-XX ROA- patient Cheque XX.XX Ø ZZ

19 See sample Financial Terms Agreement Form, Page 64 20 See sample Financial Record Form, Page 63

34

28. Correction of Entries

As previously indicated in the section on Electronic Recordkeeping, electronic files must indicate the changes to the recorded information as well as maintaining a record of the original entries. With manual recordkeeping, there are specific criteria which must be followed when making a correction of any recorded information.

The following are the required criteria:

1. At no time can correction fluid, correction tape or similar products be used. 2. At no time can an entry be erased. 3. At no time can an entry be blacked-out. 4. A straight-line strike-through of the original information to be corrected must be done in ink

and in such a manner as to allow for any reader to easily decipher the original entry. The subsequent corrected information must be entered either above the original information which has been struck out (if adequate room exists) or entered into the next available entry line or area which must then subsequently provide indication as to where this information pertains (such as the use of arrows from the corrected entry to original entry).

5. Where applicable, the corrected information requires notation as to the reasoning and/or justification for the correction.

6. Any strike-through, additions, changes and/or deletions, must be dated and signed/ initialled by the individual whom made the original entry.

7. In the case of changes to any form of consent by a patient, the patient must also provide their signature or initial to any changes.

8. Records cannot be inappropriately altered after the fact. Interlineations should not be used (in between the lines) unless it is to provide a correction of information above a strike-through and there is adequate room in which to provide a clear and concise correction entry.

The patient care notes example on page 30, shows several entries which have been appropriately corrected.

29. Forensic Matters

Forensic dentistry is an overlap of dental and legal professions.

The most common element of forensic dentistry that a denturist is likely to encounter, is the request for an antemortem (before death) patient record to assist in the identification of a deceased individual; such an individual who has not otherwise been identified due situations such as being burnt, significantly decomposed or otherwise disfigured.

The practitioner’s patient record can assist in the identification of an individual. The diagnostic models, secondary impressions, charted examination findings, digital photographs, radiographs, records of denture teeth used, natural dentition, etc., can all aid a forensic investigator in their endeavour to identify an individual.

In such a case, the forensic investigator will provide you with their authority to access your records.

35

30. Retention of Patient Records

Any and all patient records must be maintained in a safe, protected environment which will ensure integrity of the record, for a minimum of ten (10) years after the last date service(s) were provided to the patient.

The College also recommends that its Members consider whether patient records should be maintained beyond the ten (10) year period mentioned above, in order to meet any one or more of the following purposes:

1. To fulfill the requirements of any public or private health insurance plan; 2. To satisfy any applicable requirements for record retention established by a hospital or other

publicly funded healthcare entity in which the denturist provided treatment; 3. To meet business, tax, or accounting requirements; and 4. Current or potential legal recourse.

1. Deceased Patients The College recommends that its Members retain a deceased patient’s record for a minimum of ten (10) years after the last date on which treatment was provided to the patient.

2. Sale of a Practice If a Member or an individual whom owns the clinic sells the clinic, the owner is responsible for ensuring that the new owner is aware of the requirements of retention of the patient records, and should provide indication to the new owner of what amount of time has expired towards the minimum ten (10) year retention requirement for each patient record.

Further, the College recommends that the vendor provide notification of the sale of the practice to all of their patients and to advise the patients as to who is in possession of the records, where the records will be located and the appropriate contact information.

3. Closure of a Practice If a Member or individual whom owns the clinic is closing the practice, the Member or owner individual must maintain the patient records for the minimum ten (10) year period. Further, these patient records must be retained and maintained in a protective environment to prevent damage and for ease of retrieval if necessary.

Further, the College requires that notification of the closure of the clinic be provided to the College in a timely manner, and that the location where the patient records will be stored is also provided.

It is prudent that a notice of the closure of the clinic, the name of whom is in possession of the patient records, the location of where the patient records will be stored and the contact information for that individual, be provided to the patients.

4. Appointment Schedule Records It is required that the Member or individual whom owns the clinic, retain the records of Appointments, whether they are in a hard copy appointment book or electronic scheduler, for a period of at least ten (10) years.

36

31. Security, Storage and Disposal of Patient Records

1. Security of Records Patient record security relates to the methods used to protect the patient information from access, whether accidental or intentional, for unauthorized modification and/or destruction.

A. Current Patient Records-Active Files

Patient records must be handled appropriately within the clinic. Records are not to be left unattended in public areas of the clinic. Only those individuals, whom are authorized, should access the records.

Practitioners should have written policies in place to deal with the access, release, transmission and destruction of their patient records.

As well, it is prudent to have employees execute an Oath of Confidentiality to protect patient information and any employees leaving the practice, should be reminded of the requirement of continued confidentiality.

B. Physical Protection and Security

Appropriate storage and protection of patient records will reduce the possibility of the misplacement and/or loss.

Missing records may be indicative of poor record management or carelessness by the practitioner and/or their staff.

As well, reasonable precautions must be taken to safeguard the records from damage due to fire and other hazards.

C. Transmittal Security

Practitioners are to have in place, written policies to deal with the transmission of patient record information sent via mail, facsimile, or email.

The policies should address issues such as what type of information can be transmitted by which method, maintenance of security features of email programs, etc.

2. Storage of Inactive/Archived Records If patient records are to be removed from the normal clinic location for storage at an “off-site” location, it is essential that the security and protection of the integrity of the record remains. A secure controlled environment with restricted access is recommended.

A record of which files have been stored and the location of the storage must be maintained at the normal clinic location for ease of reference.


37

3. Disposal If the patient record information is no longer required and the retention period has expired, then the record may be disposed of in a manner which will ensure that the confidentiality of the record information remains. Suitable methods for disposal include:

• Confidential return of the record to the individual patient. • Physical destruction such as shredding or incineration in a controlled process whereby any

resulting material does not include any readable personal information. (This may include the use of bonded commercial companies whom provide such services).

• Rendering the personal information into a form which can no longer be identifiable.

38

32. Access to the Recorded Information

A patient record is the possession of the denturist; however, the information in the patient record belongs to the patient, not the denturist. The information is held “in trust” by the denturist for the benefit of the patient in delivery of health services.

As such, any release of this information must have prior consent from the patient or the legally authorized representative of the patient (except in specific situations where required by law).

Before a practitioner releases any of the information contained in the patient record, (outside of previously consented to disclosure such as indicated in a PIPA consent form signed by the patient), it is prudent to obtain from the patient or legally authorized representative, a written and signed consent to release the information.

You must maintain the patient records in a form which allows for access and for the ability to make a copy (including electronic data).

The original record including any referral or correspondence letters, radiographs, etc, should never be given to the patient; rather, they should only be provided with a copy even if they are only requesting to examine the record. The integrity of the original record must be maintained.

1. Patient Access

As previously indicated, patients have the right to review or request a copy of their patient record in its entirety. Such a request should be in writing from the patient and, if being dealt with by a staff member who is not familiar with the patient, verification of identity via driver’s license or other picture identification, should be obtained.

Practitioners must provide this access, except in the situation where the practitioner believes that there would be a significant likelihood of an adverse effect on the patients physical, mental or emotional health or cause harm to a third party. Practitioners must have adequate justification for a refusal to provide examination and/or a copy of the patient chart; this justification is not adequate if it relates to the practitioner’s fear of embarrassment or litigation due to remarks regarding the patient which the practitioner has entered into the record.

When a patient has accessed their record, an appropriate entry into the progress notes in the patient record must be made by the practitioner (or staff member recording on instruction from the practitioner), reflecting this access.

As well, it is prudent to allow the patient to review their record while in your attendance (or a suitable staff member), who can then interpret and explain the terminology, symbols and/or abbreviations, contained therein.

Again, the original record integrity must be maintained and any necessary steps taken to prevent the patient from altering, removing or destroying any part of the record.

Finally, it is solely the practitioner’s decision as to whether or not they charge a patient a fee for duplication of the record in whole or in part. If a fee is charged, it must be reasonable and appropriate.


39

2. Dependent Adult Patient Access

Access to a dependent adult patient’s record must be authorized by the legally authorized guardian and this must be in writing.

Further, such access to the information must be legally allowed and must be appropriately recorded into the progress notes in the patient record by the practitioner (or staff member recording on instruction from the practitioner).

3. Minor Aged Patient Access

Access to a minor aged patient’s record must be authorized by the parent of responsibility or the legally authorized representative of the minor aged patient and must be in writing.

Further, such access to the information by other family members must be legally allowed and must be appropriately recorded into the progress notes in the patient record by the practitioner (or staff member recording on instruction from the practitioner). .

40

33. Specific Situation Considerations

In the provision of services to the public, practitioners will more likely than not have some specific situations arise which do not provide for a smooth provision of services. The following provides guidelines for dealing with some such situations.

1. Refusal of Treatment and or Referral If a patient (or the legally authorized representative) refuses to consent to a recommended treatment or referral to another practitioner, this refusal must be recorded into the progress notes in the patient record by the practitioner (or staff member recording on instruction from the practitioner), and whenever possible, the patient or legally authorized representative should provide their signature at the end of the entry. Further and when appropriate, the use of a waiver which is maintained in the patient records is also a viable method of recording a refusal. Such a waiver should contain explicit information pertaining to the refusal such as:

“I, [name of patient or legally authorized representative/guardian], have chosen not to proceed with [indicate the treatment or referral] although it has been recommended by my denturist, [name of denturist] of [name of clinic]. [Name of denturist] has thoroughly explained and I understand the risks and consequences associated with my sole and independent decision not to accept the [treatment or referral] and hereby release [name of denturist] from any responsibility for any loss or damage I may suffer as a result of this refusal.”

2. Dissatisfied Patient In the event of confrontation with a patient dissatisfied with services provided, it is highly recommended that any interaction be recorded into the progress notes in the patient record by the practitioner (or staff member recording on instruction from the practitioner), including any and all attempts to resolve the issues of the patient’s dissatisfaction. If a practitioner becomes aware that the patient is planning to or has initiated legal action, it is recommended that you contact the Professional Liability Insurance Provider, to receive advice on appropriate steps.

3. Termination of Treatment If you chose to terminate treatment, the justifications must be recorded into the progress notes in the patient record by the practitioner (or staff member recording on instruction from the practitioner), and any steps taken to ensure that all legal aspects of the practitioner/patient relationship have been fulfilled such as: i. Completion of any procedures which are in progress. ii. Formal notification to the patient via registered mail, (or similar confirmable delivery method),

indicating to the patient the need for them to find another practitioner. Further, advise the patient that you will provide them with only emergency treatment for a period of two months from the date of the letter.

iii. Finally, indicate that if they wish copies of their patient record transferred to a new practitioner, that they will have to provide consent and then the copied records can be transferred. Do not send original records.

41

34. Other Required Records In addition to appropriate patient records21, the following records are also required and form part of a patient record:

I. The Appointment Schedule record22. Whether the appointment records are kept in a hard copy “appointment book” or done via a computer software program, the appointment schedule records are required to be maintained for a minimum of Ten (10) years, (with consideration of indefinite retention if possible).

For computer software program appointment schedules, it is recommended that a hard copy be printed and maintained, or as a minimum, a separate “backup” electronic record of the appointment schedule is maintained.

II. Biohazard waste disposal record23. Where applicable, such as in the case of dripping bloody gauze, impressions with blood/tissue contamination, such items are to be placed double-bagged, into a yellow biomedical waste bag, refrigerated if kept onsite for more than Four (4) days, and then disposed of by a hazardous waste management company or biomedical waste carrier, and a record of this disposal is to be maintained indefinitely.

III. Sharps disposal record24. Where applicable, such as with scalpels, burs, blades, ortho/wrought wire clasps, broken cast clasps and other sharp objects, such items are to be placed into an appropriate “Sharps” container labelled with the biohazard symbol. Once the container is full, it is to be disposed of by a hazardous waste management company or biomedical waste carrier, and a record of this disposal is to be maintained indefinitely.

21 See Section 22, Page 25 - 26 22 See Section 30, Page 35 23 See sample Biohazard Waste Disposal Record Form, Page 66 24 See sample Sharps Disposal Record, Page 67

EEExxxaaammmpppllleee CCChhhaaarrrttt DDDooocccuuummmeeennntttsss &&& FFFooorrrmmmsss

42

35. Example Chart Documents The following are examples of various parts of patient charting and forms, which in combination would ultimately form part of the patient record.

The choice of patient charting and how extensive the charting is, is ultimately that of the individual practitioner, however, the best patient chart is one that is used and completed consistently and with consideration of the requirements of basic recordkeeping.

The following examples provide a guideline of the components of an appropriate patient chart.

The use of any or all of these documents is solely a choice of the individual and the College is not responsible in any way shape or form for the use or lack of use of the examples.

However, the College considers these documents to be a reference of the appropriate level of information necessary, for that portion of the patient record.

This does not imply or indicate legal advice by the College; it is recommended that you seek independent legal advice regarding the use of these charts and forms.

43

Personal Information Protection Act Consent Form

(Practitioner Name and or Clinic Name) In our office, we are dedicated to ensuring the protection of our patients’ personal information and insuring that this information is used only in a professional manner. The following indicates some of the information that is collected, why we collect it, and when we may disclose your personal information. We collect, use and disclose your personal information where permitted or required by law. Contact Information We collect contact information from our patients such as full name, home address, home telephone number(s), home email address, work address, work telephone number(s), work email address, and cellular phone number. This information is considered as Contact Information and it is collected for a variety of purposes including the following:

To open and update a patient file;

To invoice patients for dental services, to process credit card payments, or to collect unpaid accounts;

To process claims for payment or reimbursement from a third-party health benefit provider or insurance company*;

To send correspondence to our patients regarding need for further examination or treatments; and

To send correspondence to our patients regarding our clinic and practice.* Contact information is/may be disclosed to a third party health benefit provider or insurance company when submitting a claim on the patients’ behalf, for payment or reimbursement of all or part of the cost of the treatment provided, or when a patient has requested a preauthorization of a proposed treatment.

Medical/Dental History We collect from our patients, information about their health history, family health history, physical and mental condition, their dental health history, and family dental health history. This Medical/Dental information is collected for a variety of purposes and may be used in part to assist us in diagnosing dental conditions and providing appropriate treatment for you, and may be disclosed for the following purposes:

To a third-party health benefit provider or insurance company, in the submission of a claim on behalf of the patient, for reimbursement or payment of all or part of the cost of the treatment ;

To a third-party health benefit provider or insurance company on behalf of the patient, in the submission of a preauthorization of treatment;

To other health/dental providers where, upon your consent, we are seeking a second opinion;

To other health/dental providers where, upon your consent, we have referred you to for additional\alternative treatment;

Financial Information

We collect information related to financial matters for facilitation of payment of your treatment(s).

Future Use

If consideration to sell this practice or a portion of this practice ever occurs, any qualified potential purchasers may be granted access as part of due diligence process to patient information, in order to verify information related to the sale. If this ever occurs, we will take necessary steps to ensure that the prospective purchaser protects any personal information, as we have done.

Regulatory

The College of Alberta Denturists regulates all Denturists in the Province of Alberta and as part of their regulatory function, may inspect our records and interview our staff in the process of their duties.

Consent

I hereby authorize and consent to the collection, use and disclosure of personal information concerning myself with regards to the above purposes, dated at the City/Town of in the Province of Alberta, on the day of ___________, 200 . (Patient/Guardian Name) (Patient /Guardian Signature)

44

Denture Clinic 123 Any Street Some City, Alberta, T0T 0T0

Personal Information: Please Print or place an “X” into the appropriate box(es) Date:

MM/DD/YYYY

Name: Last First Second Used

Date of Birth Gender: Female Male MM/DD/YYYY

Home Address: Home Phone: City: Work Phone: Province: Postal Code: Cellular Phone: Home Email: Work Email: Physician: Phone: Dentist: Phone: Previous Denturist: Phone:

Hygienist: Phone: Referred by: Profession/Relation: Phone: Legal Guardian (if applicable): Contact Number: In Case of Emergency, contact: Contact Number:

Relationship: Cellular Number:

Your Occupation:

Your Living Environment: Do you require medical devices or equipment such as oxygen, walker, cane, etc? ……… Yes No

If yes, please describe: Your Personal Accommodation Private Residence Multifamily dwelling Assisted Living Nursing Home

Individual Responsible For Account:

Patient Guardian Insurance & Patient Insurance & Guardian

(For insurance, complete an insurance information form)

Office Use Only

Medical History Alert Numbers: ___________________________________

Dental History Alert Numbers: ___________________________________

45

Patient Name: Date: MM/DD/YYY

Medical Health History

1. Are you currently under the care of a physician? ……………………………………………….…. Yes No If yes, what for?

2. Have you ever had any serious illness or been hospitalized? ……………………………............ Yes No If yes, what for?

3. Please place an “X” into the appropriate box for the listed health issues. Indicate yes if you have had the condition even if you do not currently have that condition.

YES NO YES NO Alcohol problems: HIV / AIDS: Drug Dependency- Specify: Sexual Transmitted disease: Environmental Allergies. Specify: Immune Deficiency: Food Allergies. Specify: Herpes Virus (cold sores) : Latex Allergy: Other Allergies. Specify: Kidney Disease:

Kidney Stones: Asthma: Chronic Obstructive Pulmonary Disease: Heart Attack: Difficulty breathing: Heart Disease: Emphysema: Rheumatic Fever: Tuberculosis: Heart Murmur:

Heart Surgery: Hepatitis A: Artificial Heart Valve: Hepatitis B: Pacemaker: Hepatitis C: Angina pectoris: Other Liver Disease: Specify:

Cholesterol problems: Arthritis: High Blood Pressure: Artificial Joint replacement- Specify: Low Blood Pressure:

Bleeding Disorder/Haemophilia: Stroke:

Cancer. Specify: Chemotherapy/Radiation therapy: Nervousness/Psychiatric condition:

Diabetes Type 1: Organ Transplant : If yes, specify: Diabetes Type 2: Eating disorder. If yes: anorexia bulimia Thyroid Disease. If yes: Hyper Hypo

Epilepsy or Seizures: Surgeries- specify: Dizziness/fainting:

Other. Specify: Office Use Only:

4. Have you ever experienced a bad reaction to any of the following medications: Medication Yes No Never Used Medication Yes No Never Used Anaesthetic Penicillin Barbiturates (sleeping pills) Sulphonamides (sulpha) Codeine Tranquilizers Cortisone (steroids) Other- please list: 5. Are you taking any medications, over the counter medications or herbal remedies? ………….. Yes No If yes, what? If yes, what for?

6. Are you allergic to any foods, metals or latex? …………..………………………..…. Yes No If yes, please list:

46

7. Have you recently lost or gained a significant amount of weight? ……………………………….. Yes No If yes, how much? ……………………………………..…………….......... Gained: kg/lbs Lost: kg/lbs

8. Do you smoke or use chewing tobacco? ……………………………………………………………. Yes No If yes, which and for how long?

9. Do you frequently have indigestion? ………………………………………………………………… Yes No

10. If yes to question #10, do you take anything for the indigestion? ………………………………… Yes No If yes, what do you take?

11. Are you pregnant? ………………………………………………………………………………………. Yes No NA : Male

12. Do you have any other health issues which have not been addressed above?………….………... Yes No If yes, please list:

Office Use Only

Additional Notes related to Responses on the Medical History

Question Number

Notes

47


Dental Health History Please place an “X” into the appropriate box or provide your written response

1. When was your last dental visit? ………………………………..……. 2. What procedures did you have done at that visit? ……………….… 3. Have you had any complications following a dental procedure? ................................................ Yes No

If yes, please explain 4. Have you had dental x-rays done in the last two (2) years? …………..………………………....... Yes No 5. Do you have any dental work ongoing at this time? ……………………………..………..………... Yes No 6. Do you have any outstanding dental work to be done? …………………………………..………... Yes No

If yes, what procedures need to be done?

7. Have you had any complications following a dental procedure? ………………………………..... Yes No

If yes, please specify: 8. Do you have any sensitive teeth (if applicable)? ……………………………………………………. Yes No 9. Do your gums bleed (if applicable)? ………………………………………………………………..... Yes No 10. Do you normally have a bad taste in your mouth?..………………………………………………… Yes No 11. Do you normally have an unpleasant odour/taste in your mouth? ………………………………... Yes No 12. Do you have any pain in your jaw joint? …………………………………………………….............. Yes No

13. Do you clench or grind your teeth? ............................................................................................. Yes No 14. Do you have dental implants? ………………………………………............................................... Yes No 15. Have you ever had an accident or had trauma/injury to your neck or jaws? ............................... Yes No If yes, specify: 16. Do you have any pain or numbness in your head, neck or jaws? …….…………………………... Yes No If yes, specify: 17. Do you have any sore spots or anomalies in your mouth? .……………………………................ Yes No 18. Do you have any habits which affect your mouth such as mouth breathing, chewing objects,

chewing nails, etc? ……………………………………………………………………………………... Yes No

If yes, specify: 19. Have you been diagnosed with Sleep Apnea? ………………..……….………………………..... Yes No If yes, by who? Phone: 20. Do you have any other dental health issues which have not been addressed above? ………… Yes No If yes, please specify:

Complete the following questions only if you have some or all of your natural teeth

21. How often do you brush your teeth? Daily Weekly Other (specify) 22. How often do you floss your teeth? Daily Weekly Other (specify) 23. How often do you see a Hygienist? Yearly Bi-Yearly Other (specify)

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Complete the following questions only if you have a denture or dentures

24. What type of dentures do you have? (complete or partial) Complete: Upper: Lower: Partial: Upper: Lower:

25. When were your dentures made?..…….……………............. Upper: (year) Lower: (year) 26. Who provided you with the dentures? ……..…………………. Upper: Unknown/Prefer not to say Lower: 27. Do your gums get sores under your denture(s)? …………... Upper Yes No Lower Yes No If yes, how often Daily Weekly Occasionally Other (Specify): 28. Do you brush your gums under your denture(s)? …….....….. Upper Yes No Lower Yes No 29. Do you wear your denture(s) at night (if applicable)? …...….. Upper Yes No Lower Yes No 30. How many dentures have you had (if applicable)? …............ Upper: Lower: 31. Are you happy with the appearance of your dentures? …………………………………………….. Yes No 32. Do you have problems eating any particular types of food? …………………………………….. Yes No 33. Do you use denture adhesives? ………………………………………………………………………. Yes No 34. Have the benefits of dental implants been discussed with you? ………………………………... Yes No

“I the undersigned, hereby certify that all of the medical and dental information provided on

this form to be true to the best of my knowledge and that I have not knowingly omitted any

information. I also consent to my family physician/family dentist being contacted, if

necessary, to obtain further information or clarification of medical/dental conditions as is

necessary for my denturist treatment.”

Dated this ____ day of __________, 20___.

______________________________________ Patient Signature

Office Use Only Notes related to Responses on the Dental History

Question Number

Notes

The Medical and Dental History has been reviewed by myself and discussed with the patient: Practitioner Signature:

49

Patient Name: Date: MM/DD/YY

Medical & Dental History Update

1. Is there any change to your medical &/or dental history information since your last visit? …................................................................................................................... Yes No

2. Have you been to your physician and/or dentist lately? .....…………………………. Yes No

3. Is there a change to your listed prescription medications? …………………………... Yes No

4. Has there been a change to your listed allergies? ……………………………………. Yes No

5. Do you have any heart problems? ……………………………………………………… Yes No

6. Have you had a joint replacement since your last visit? ……………………………… Yes No

7. Have you been in contact with any individual that has Tuberculosis? ……………… Yes No

Office Use Only

Notes related to Responses on the Medical History Update

DATE Changes to Medical /Dental History Patient Denturist MM/DD/YY NONE Note Changes Signature Signature

50

Patient Name: _____________________________________ Date: ________________ Last First Second Used MM/DD/YYYY

Examined By: Signature: .

Extraoral Findings

1. Cursory observation of physical health WNL Excellent Poor:

2. Physical stature WNL Stooped Unsymmetrical Paralysis

3. Movement WNL Limited Assisted: Cane Walker Wheel Chair

4. Communication skills Excellent Acceptable Problematic:

5. Facial Structure Square Tapering Ovoid Other:

6. Facial Symmetry WNL Unsymmetrical:

7. Neck WNL Abnormal:

8. Lymph Nodes WNL Abnormal:

9. Salivary Gland Palpation

Left WNL Abnormal: Right WNL Abnormal:

10. TMJ vertical movement Left WNL Abnormal: Right WNL Abnormal:

11. TMJ lateral movement Left WNL Abnormal: Right WNL Abnormal:

12. TMJ conditions Left Crepitis Click/pop Pain Other: Right Crepitis Click/pop Pain Other:

13. Facial/Head pain Left WNL Temple area Eye area Back of Head/Neck Shoulder Right WNL Temple area Eye area Back of Head/Neck Shoulder

14. Muscle Tenderness / Pain None Present- Location(s):

_______________________________________________________________

15. Labial Commissure WNL Collapsed Irritated/abnormality:

16. Upper Lip WNL Collapsed Irritated/abnormality:

17. Lower Lip WNL Collapsed Irritated/abnormality:

18. Lesions None Present- Location(s): _______________________________________________________________

Additional Notes to Extraoral Findings:

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Intraoral Findings

General

1. Interach anterior relation WNL Retrognathic Prognathic

2. Interach posterior relation WNL Crossbite: Bilateral Crossbite: Unilateral-

Right side Left side Crossover Point

3. Interach spacing Average Excessive Minimal/Restricted

4. Arch parallelism Parallel Maxillary Divergent Mandibular Divergent

5. Arch size Maxillary to Mandibular WNL Maxillae larger Mandible larger

6. Saliva WNL Excessive Limited Consistency:

7. Tongue Size WNL Macroglossia Microglossia

8. Tongue Mobility WNL Excessive Restricted Thrusting

9. Cheek Mucosa Left WNL

Irritated: Pathologic:

Right WNL Irritated: Pathologic:

10. Pharynx WNL Irritated; Pathologic:

11. Floor of Mouth WNL Irritated: Pathologic:

Additional Notes on General Findings:

Maxillary Arch

12. Arch Form Square Tapering Ovoid Other:

13. Shape of Ridge Supportive Tapering Inadequate

14. Ridge Classification A: B: C: D: E:

Alveolar bone

Basal bone

15. Contour of Palate Broad/Flat U-shaped V-shaped

16. Contour of soft palate Gradual More sloping Sharp slope

17. Palatal sensitivity None Minor response Violent response

18. Tuberosities Supportive Distorted Inadequate Mobile

19. Soft Tissues Firm 1mm Over 1mm Flabby:

20. Mucosal condition WNL Irritated: Trauma: Pathologic:

21. Frenal Attachments Low Medium High

22. Tissue Border Attachment

Favourable > 12mm

Restricted 8-12mm

Inadequate < 8mm

23. Torus Absent Small Large Location:

24. Bony Undercuts Absent Small Large Location: Additional Notes on Maxillary Arch:

52

Mandibular Arch

25. Shape of Ridge Supportive Tapering Inadequate Knife Edged

26. Arch Form A: B: C: D: E:

Alveolar bone

Basal bone

27. Lateral Throat Form Distolingual Undercut

Left Level < 15 mm >15 mm

Right Level < 15 mm >15 mm

28. Soft Tissues Firm 1mm > 1mm Flabby

29. Mucosal condition WNL

Irritated:

Trauma:

Pathologic:

30. Frenal Attachments Low Medium High

31. Tissue Border Attachment

Favourable > 12mm

Restricted 8-12mm

Inadequate < 8mm

32. Torus Absent Small Large Location: 33. Bony Undercuts Absent Small Large Location: Additional Notes on Mandibular Arch:

Pathology

No Apparent Pathology Present

1. Pathology Present Maxillary- location: Mandibular-location:

2. Pathology Appearance Maxillary: Mandibular:

3. Appearance Maxillary:

Mandibular:

4. Action Maxillary Mandibular

Observe Observe

Referred- to: Referred to:

Additional Notes on Pathology:

53

Implantology

No Dental Implants Present

1. Implants Present Maxillary Anterior- site: Posterior: site: Mandibular Anterior- site: Posterior- site:

2. Implant Type Maxillary: Mandibular;

3. Implant Size Maxillary: Mandibular:

4. Date Implanted Maxillary: Mandibular:

5. Placing Practitioner Maxillary: Mandibular:

6. Implant Retention Maxillary Mandibular

Ball Ball

Bar Bar

Fixed Fixed

Other Other

7. Attachment Information (Retentive devices)

Maxillary: Mandibular:

Additional Notes on Implantology:

Pathology

No Apparent Pathology Present

5. Pathology Present Maxillary- location: Mandibular-location:

6. Pathology Appearance Maxillary: Mandibular:

7. Appearance Maxillary:

Mandibular:

8. Action Maxillary Mandibular

Observe Observe

Referred- to: Referred to:

Additional Notes on Pathology:

54

Patient Name: _____________________________________ Date: ________________ Last Used MM/DD/YYYY

Evaluation of Existing Dentures

1. Complete Denture Upper Complete Partial Lower Complete Partial

2. Removable Partial Denture

Upper Chrome Cobalt Acrylic Titanium Other: Lower Chrome Cobalt Acrylic Titanium Other:

3. Jaw relationship Orthognathic Retrognathic Prognathic

4. Anterior Overjet WNL None Minimal Excessive

5. Buccal Overjet Left WNL None Minimal Excessive Right WNL None Minimal Excessive

6. Crossbite N/A

Left Crossover point Right Crossover point

7. Centric Occlusion in harmony with Centric Relation

Yes No (details)

8. Existing interocclusal distance mm

Estimated via closest speaking space at premolars Physical measurement

9. Lateral excursions WNL Fair Poor

10. Protrusive excursions WNL Fair Poor

11. Esthetic appearance WNL Fair Poor

12. Tooth to Ridge Relationship WNL Unacceptable:

13. Maxillary Retention N/A WNL Adequate Inadequate

14. Mandibular Retention N/A WNL Adequate Inadequate

15. Maxillary Extensions N/A WNL Unacceptable:

16. Mandibular Extensions N/A WNL Unacceptable:

17. Type of Occlusion Max 0º 10º 20º 30º Other Man 0º 10º 20º 30º Other

18. Plane of Occlusion WNL Inferior slope Superior rise

19. Tooth Composition

Max Anterior Plastic Composite Porcelain Other

Max Posterior Plastic Composite Porcelain Other

Man Anterior Plastic Composite Porcelain Other

Man Posterior Plastic Composite Porcelain Other

20. Denture Teeth Condition WNL Fair Poor

21. Denture Base Condition WNL Fair Poor

22. Condition of Framework WNL Fair Poor

Additional Notes on Existing Dentures:

55

Patient Name: _____________________________________ Date: ________________ Last Used MM/DD/YYYY

New Denture Registration Information

1. New Registration Information Previous Interocclusal Distance: mm

Estimated via closest speaking space at premolars Physical measurement

New Interocclusal Distance: mm Estimated via closest speaking space at premolars Physical measurement

2. Lateral Excursions WNL Fair Poor

3. Protrusive excursions WNL Fair Poor

4. Esthetic appearance WNL Fair Poor

5. Maxillary Retention N/A WNL Fair Poor

6. Mandibular Retention N/A WNL Fair Poor

7. Type of Occlusion Max 0º 10º 20º 30º Other Man 0º 10º 20º 30º Other

8. Plane of Occlusion WNL Inferior slope Superior rise

9. Tooth Composition

Max Anterior Plastic Composite Porcelain Other Max Posterior Plastic Composite Porcelain Other Man Anterior Plastic Composite Porcelain Other Man Posterior Plastic Composite Porcelain Other

10. Teeth Used

Max Anteriors Max Posteriors Man Anteriors Man Posteriors

11. RPUD Framework Material CC Ti Acrylic Thermoplastic/Flexible Other

12. RPLD Framework Material CC Ti Acrylic Thermoplastic/Flexible Other

13. RPUD Clasp Material CC Ti WW Thermoplastic/Flexible Other

14. RPLD Clasp Material CC Ti WW Thermoplastic/Flexible Other

Notes:

56

Odontogram Patient Name: Date: Practitioner: Signature:

Anatomic

57

Periodontal Screening & Recording and Tooth Mobility Measurement Record Patient Name: Date: Practitioner: Signature:

Date

Tooth Mobility Measurement Record

Legend N: Normal

1: Slight mobility:

< 1 mm

2: Moderate mobility

> 1 mm < 2 mm

3: Severe mobility: > 2 mm and may

move vertically as well as horizontally

1.8 1.7 1.6 1.5 1.4 1.3 1.2 1.1 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8

4.8 4.7 4.6 4.5 4.4 4.3 4.2 4.1 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8

58

Patient Name: Progress Notes

Date Description Signature

59


Treatment Options Form

Subjective Info: Patient Concerns

Objective Info: Examination Concerns

Assessment Info: Diagnosis

1

Proposed Treatment: No Treatment Fee: $ No Fee Treatment Specifics: Nothing to be done Initial Prognosis: Excellent Good Guarded Poor Predicted Results: Concerns &/or future maintenance procedures

3

Proposed Treatment: Link to Diagnosis

Treatment Specifics: Appointments, procedures, materials, etc.

Initial Prognosis: Excellent Good Guarded Poor

Predicted Results: Concerns &/or future maintenance procedures

Total Fees:$ Fees Breakdown:

4






-OVER-

2






60

CONSENT TO TREATMENT

I, ___________________________, have been advised of the aforementioned treatment plans (including risks, benefits and predicted outcomes) and I have chosen to accept Option ,

and I hereby provide my expressed consent for the treatment and further, that I understand and agree that I am responsible for the fees associated with the treatment(s):

_________________________________________ Patient Signature

Dated this ______ day of __________________, 200__.

I hereby verify that I have fully reviewed the aforementioned treatment plans with this patient, including the risks, benefits and predicted outcomes.

Practitioner Signature: ___________________________________________

Date: __________________ MM/DD/YYYY

61

An Alberta Denture Clinic Dental Insurance Company Information Form 123 Any Street Some City, Alberta, T0T 0T0

Patient Name: Last First

Primary Insurance Company Company Name: Policy Number: Address: Group Number: Class: Subscriber:

Patient _________________ Last First

ID Number:

Subscriber Date of Birth: _________________ MM/DD/YYYY

Place of Employment:

Subscriber Phone: Coverage (if known) % Additional Information:

Secondary Insurance Company

Company Name: Policy Number: Address: Group Number: Class: Subscriber:


ID Number:




Additional Insurance Company

Company Name: Policy Number: Address: Group Number: Class: Subscriber:


ID Number:




Method of Payment for non-insured portion(s)

Invoice Patient/Guardian Credit Card on file and authorized Financial Terms Agreement on file

62

An Alberta Denture Clinic Partial Denture Prescription 123 Any Street Some City, Alberta, T0T 0T0 Phone: (780) 123-4567 Email: [email protected]

Today’s Date: Date Required: Patient’s Name: Last First

Dental Lab: Phone:

Complete a separate form for each framework.

1.2 2.1 1.1

1.3

1.4

1.5

1.6

1.7

2.2

2.3

2.4

2.5

2.6

2.7

4.7

4.6

4.5

4.4

4.3 4.2 4.1 3.1

3.3

3.2

3.4

3.5

36

3.7

1. Major Connector:

2. Support/Indirect Retainers (rests):

3. Guide Plates:

4. Direct Retainers:

5. Reciprocation (bracing):

6. Resin Retention:

7. Special Instructions:

8. Additional Information:

Signature:

Colour Code Red – Cast Metal Components Blue- Wrought Wire Components and Acrylic Resin Bases Green- Tooth Modifications (Guide planes, rest preps)

Tooth Surface Notation

O – Occlusal D – Distal La – Labial In – Incisal M – Mesial Bu – Buccal Li – Lingual

Framework Material

Chrome Cobalt Titanium Gold Other:

63

An Alberta Denture Clinic Financial Record 123 Any Street Some City, Alberta, T0T 0T0

Date Procedure Code Amount Balance Signature

Name: Last First Second Used

Home Address: Home Phone:

City: Work Phone:

Postal Code: Cellular Phone:

Method of Payment: Cash Cheque Visa MasterCard Debit Insurance

Primary Insurance Co: Policy Number:

Subscriber: ID Number:

Secondary Insurance Co: Policy Number:

Subscriber: ID Number:

Individual Responsible for Account: Self Other: name ______________________________________

64

An Alberta Denture Clinic Financial Terms Agreement 123 Any Street Some City, Alberta, T0T 0T0 Patient Name: Date:

MM/DD/YYYTreatment Fees Financial Terms Agreement

Consented To Treatment Fees Total $

Deposit Required $

Expected Insurance Payment $

Expected Balance $

Payments Required Date Amount Payment Method Balance

$ Visa MasterCard Cheque Debit Cash $ $ Visa MasterCard Cheque Debit Cash $ $ Visa MasterCard Cheque Debit Cash $ $ Visa MasterCard Cheque Debit Cash $ $ Visa MasterCard Cheque Debit Cash $ $ Visa MasterCard Cheque Debit Cash $

Agreement to Financial Terms

I, _______________________, have consented to the aforementioned treatment plan and I accept the total fees for the treatment, and I understand and agree that I am responsible for the total

fees associated with the treatment.

I agree to the terms indicated herein regarding payment of the fees.

_________________________________________

Patient Signature

Dated this ______ day of __________________, 200__.

Practitioner Signature: ___________________________________________

Date: __________________ MM/DD/YYYY

65

An Alberta Denture Clinic Credit Card Authorization Form 123 Any Street Some City, Alberta, T0T 0T0 Phone: (780) 123-4567 Email: [email protected]

I authorize <denture clinic name>, to charge my credit card as detailed below:

Please maintain my signature on file for payment of any consented to treatment fees, and to charge the full amount of the fees upon completion of the treatment.

Please maintain my signature on file for payment of any consented to treatment fees and to charge the estimated portion due upon completion of the treatment.

Please maintain my signature on file for payment of any consented to treatment fees and to charge any portion due upon completion of the treatment for any unpaid balance after receipt of insurance payment.

Patient Name: Responsibility Individual’s Name: Address: Phone Number:

Credit Card: VISA MasterCard American Express Card Number: Expiry Date: Name on Card:

Authorized Signature:

This authorization will remain valid until such authorization is removed in writing by the aforementioned patient.

66

An Alberta Denture Clinic Biohazardous Waste Disposal Record 123 Any Street Some City, Alberta, T0T 0T0 Phone: (780) 123-4567 Email: [email protected]

Waste Description Autoclaved # of Bags -Containers

Total Weight(kilograms)

Waste Disposal Company Date DisposedMM/DD/YYYY

Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No

67

An Alberta Denture Clinic Sharps Waste Disposal Record 123 Any Street Some City, Alberta, T0T 0T0 Phone: (780) 123-4567 Email: [email protected]

Sharps Container

If no: method of storage

Autoclaved Total Weight(kilograms)

Waste Disposal Company Date DisposedMM/DD/YYYY

Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No

EEExxxaaammmpppllleee RRReeefffeeerrrrrraaalll FFFooorrrmmmsss

68

36. Example Referral Forms

The following are examples of referral forms which can be utilized by the practitioner.

Such forms, when utilized, must be copied and the copy maintain in a patient’s record.

The use of any or all of these example forms is solely a choice of the individual practitioner. The College is not responsible in any way shape or form for the use or lack of use of the samples and further, this does not imply or indicate legal advice by the College; it is recommended that you seek independent legal advice regarding the use of these forms.

69

An Alberta Denture Clinic Practitioner Referral Information 123 Any Street Some City, Alberta, T0T 0T0 Phone: (780) 123-4567 Email: [email protected]

Today’s Date:

Patient’s Name: Birthdate: Last First MM/DD/YYYY

Telephone: Home: Work: Gender: Female Male

Referred to: Phone:

Clinic Address:

Appointment: Date: Time: Bill: Patient Denture Clinic

Purpose of Referral Examination of remaining dentition for necessary restorations prior to partial denture treatment

Examination of remaining dentition for viability Tooth preparations for partial denture treatment Analysis of tissue: (location and presentation)

Implant consultation: (specify location)

Other: (specify)

Documents/Items Enclosed Radiographs: (specify)

Photographs: (specify)

Diagnostic Models: Upper Lower

Articulated Models: Current Registration Proposed Registration

Partial Denture Diagnostic Prescription Other: (specify):

Page 1 of 2

70

Proposed Treatment Plan(s)

Relevant Notes/Special Instructions

Interpretation & Results

Return radiographs to denturist Return photographs to denturist

Return partial denture prescription

Return models to denturist Return articulation to denturist

Please provide your findings/recommendations: with returned items via email via mail with the patient

Referral Authorization

Denturist Name: Denturist Signature: Registration Number: 80920XXX

Email:

We thank you for your cooperation with this patient!

Page 2 of 2

71

An Alberta Denture Clinic Radiograph Referral & Requisition 123 Any Street Some City, Alberta, T0T 0T0 Phone: (780) 123-4567 Email: [email protected]

Today’s Date:

Patient’s Name: Birthdate: Last First MM/DD/YYYY

Telephone: Home: Work: Gender: Female Male

Referred to: Phone:

Clinic Address:

Appointment: Date: Time: Bill: Patient Denture Clinic

Radiographs Panoramic Cephalometric Occlusal: Maxillary Mandibular

PA- specify site(s):

Scans TMJ Left Right Sinus

Implant- Maxillary-specify site(s):

Implant- Mandibular-specify site(s):

Pathology Investigation-specify site & concern:

Interpretation Return original radiographs to denturist Return radiographs to denturist via email Radiologist report: with copy of radiographs without copy of radiographs via email

Relevant Notes/Special Instructions

Referral Authorization

Denturist Name: Registration Number: 80920XXX Denturist Signature:

Email:

72

37. Bibliography The following is an alphabetical listing of sources of information which was utilized in the development of this manual, and is divided into the categories of the material which was reviewed. NAIT NAIT Dental Health Sciences Department - various Instructional Publications Website Documents Note: Website addresses were active at time of obtaining the documents.

American Academy of Pediatric Dentistry- Clinical Guideline on Record-keeping http://www.aapd.org/media/Policies_Guidelines/G_Recordkeeping.pdf

American Dental Association – Dental Records http://www.ada.org/prof/resources/topics/dentalpractice_dental_records.pdf

Boston University- Dental Record Protocol http://dentalschool.bu.edu/treatment-policies/dental-record-protocol.html

College of Dental Surgeons of British Columbia- Dental Records Management http://www.cdsbc.org/pdf/Dental-Records-Mgt.pdf

College of Physicians & Surgeons of Alberta http://www.cpsa.ab.ca/publicationsresources/policies.asp

College of Physicians & Surgeons of Ontario- Medical Records http://www.cpso.on.ca/Policies/medical%20records/medical_records.pdf

College of Physicians & Surgeons of Ontario- Guidelines for Medical Record-keeping http://www.cpsns.ns.ca/publications/2006-medical-record.pdf

CNA HealthPro- Recordkeeping Self-Assessment Checklist http://professional.protectorplan.com/pdfs/RiskManagement/Records%20Checklist.pdf

Denis Rucci – If it’s in the Chart – it Happened http://www.sfvds.org/membership/pdf/summer04/dd_summer04.pdf

Delta Dental- Quality Assessment Program Criteria http://www.deltadentalins.com/index.html

Forensic Dentistry Online http://www.forensicdentistryonline.org/Forensic_pages_1/dental_records.htm

Government of Alberta – Queen’s Printer http://www.qp.gov.ab.ca/documents/Acts/D11.cfm?frm_isbn=9780779723799 http://www.qp.gov.ab.ca/documents/Acts/F04P5.cfm?frm_isbn=0779740718

Harris County Psychiatric Center & University of Texas – Progress Notes http://hcpc.uth.tmc.edu/procedures/volume2/chapter3/treatment_services-29.htm

Royal College of Dental Surgeons of Ontario – Dental Recordkeeping http://www.rcdso.org/pdf/guidelines/dental_recordkeep.pdf

Medical Training Resources - Writing a SOAP Note manual http://www.medtrng.com/soapnotes.htm

Progress Notes Model http://www.amia.org/pubs/symposia/D004372.PDF

73

Queen’s School of Medicine – The Medical Record http://meds.queensu.ca/courses/phaseiii/home/phase_iii_policies

TrueNorth – various medical dental history forms http://www.truenorthhealthcenter.org/forms.asp

Wikipedia – Medical Record http://en.wikipedia.org/wiki/Medical_record

Wikipedia – SOAP note http://en.wikipedia.org/wiki/SOAP_note

Books Writing SOAP Notes: With Patient/Client Management Formats, 3rd Edition ISBN-13: 978-0-8036-0836-8 ISBN-10: 0-8036-0836-5 Boucher’s Prosthodontic Treatment for Edentulous Patients, 11th Edition ISBN-13: 978015198994 Dental Management of the Medically Compromised Patient ISBN: 0-8016-6837-9 Dental Drug Reference ISBN: 9780323052665 Oral Roentgenographic Diagnosis, 4th Edition ISBN: 0-7216-8547-1 An Atlas of Removable Partial Denture Design ISBN: 0-86715-190-0 McCracken’s Removable Partial Prosthodontics ISBN-13: 9780801679643 ISBN: 0801679648 Occlusion ISBN: 0-7216-7439-9 Contemporary Implant Dentistry ISBN: 0-8016-6073-4 Oral Pathology ISBN: 0-7216-2433-2 Oral & Maxillofacial Radiology ISBN: 0-7216-3070-7 Nutrition in Clinical Dentistry ISBN: 0-7216-2423-5

These Guidelines were Approved by Council, on April 07th, 2008.

Copyright© College of Alberta Denturists - April 09, 2008, Registration Number: 1057342.