the patient record chapter 26 copyright © 2009, 2006 by saunders, an imprint of elsevier inc. all...

The Patient RecordThe Patient Record

Chapter 26Chapter 26

Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.


Lesson 26.1Lesson 26.1


Learning ObjectivesLearning Objectives

Pronounce, define, and spell the Key Terms.Pronounce, define, and spell the Key Terms. Identify the purpose of a patient record.Identify the purpose of a patient record. Describe each form in the patient record.Describe each form in the patient record. Supervise the completion of a new patient-Supervise the completion of a new patient-

registration form.registration form.


IntroductionIntroduction

The patient record is the principal document The patient record is the principal document containing critical information you will need to containing critical information you will need to manage each patient in the dental practice.manage each patient in the dental practice.


Fig. 26-1 Example of the patient record. Fig. 26-1 Example of the patient record. (From Gaylor LJ: (From Gaylor LJ: The administrative dental assistantThe administrative dental assistant, Philadelphia, 2006, Saunders.), Philadelphia, 2006, Saunders.)


Critical InformationCritical Information

Before dental treatment, the dental team must Before dental treatment, the dental team must have the following information:have the following information: Patient registrationPatient registration Medical-dental health historyMedical-dental health history Medical-alert informationMedical-alert information


The Patient Record The Patient Record

Permanent record Permanent record Personal and legal documentation of the patient Personal and legal documentation of the patient

Quality assurance Quality assurance Primary source of information used by the dental Primary source of information used by the dental

team to determine the overall quality of care the team to determine the overall quality of care the patient has received. patient has received.


Examples of Quality AssuranceExamples of Quality Assurance

Routine forms completed by each patientRoutine forms completed by each patient Timely recall of patients for their dental needs Timely recall of patients for their dental needs Completed patient record for each “active” patient Completed patient record for each “active” patient Documentation of when radiographs were taken Documentation of when radiographs were taken Current and up-to-date emergency standards Current and up-to-date emergency standards

maintained by the dental team maintained by the dental team Current and up-to-date licenses, registrations, Current and up-to-date licenses, registrations,

and trainingand training


The Function of the Patient RecordThe Function of the Patient Record

Risk managementRisk management The patient record provides documentation of the The patient record provides documentation of the

patient’s condition, diagnoses, and treatment and patient’s condition, diagnoses, and treatment and the patient’s responses to treatment.the patient’s responses to treatment.

Research Research The patient record provides a source of data for The patient record provides a source of data for

research purposes.research purposes.


Getting to Know Your Patients Getting to Know Your Patients

Information-gatheringInformation-gathering Address the patient, using his or her surname.Address the patient, using his or her surname. Give the reason for obtaining the information.Give the reason for obtaining the information. Answer any questions the patient may have.Answer any questions the patient may have.


Patient-Registration FormPatient-Registration Form

Patient information: full name, date of birth, Patient information: full name, date of birth, residence, phone number, employment, spouse’s residence, phone number, employment, spouse’s informationinformation

Insurance information: employee’s name and date Insurance information: employee’s name and date of birth; employer’s name, address, and phone of birth; employer’s name, address, and phone number; name of insurance carrier and policy number; name of insurance carrier and policy numbernumber

Responsible party: person responsible for Responsible party: person responsible for payment of the accountpayment of the account

Signature and date: verifies the accuracy Signature and date: verifies the accuracy of information of information


Fig. 26-4 Example of a patient-registration form.Fig. 26-4 Example of a patient-registration form. (From Gaylor LJ: (From Gaylor LJ: The administrative dental assistantThe administrative dental assistant, Philadelphia, 2006, Saunders.), Philadelphia, 2006, Saunders.)



Lesson 26.2Lesson 26.2


Learning ObjectivesLearning Objectives

Discuss the importance of the patient’s Discuss the importance of the patient’s medical-dental health history and its medical-dental health history and its relevance to dental treatment.relevance to dental treatment.

Obtain a completed medical-dental health-Obtain a completed medical-dental health-history form for a new patient.history form for a new patient.

Prepare and organize a patient record.Prepare and organize a patient record.


Medical-Dental Health History Form Medical-Dental Health History Form

Medical-history section Medical-history section Questions regarding the patient’s medical history, Questions regarding the patient’s medical history,

present physical condition, chronic conditions, present physical condition, chronic conditions, allergies, and medications currently being takenallergies, and medications currently being taken

Dental-history sectionDental-history section Information about the patient’s previous dental Information about the patient’s previous dental

treatment and care and how the patient feels treatment and care and how the patient feels about dentistry and how important dental care is to about dentistry and how important dental care is to him or her him or her


Fig. 26-5 Example of a medical-dental health-history form.Fig. 26-5 Example of a medical-dental health-history form. (From Gaylor LJ: (From Gaylor LJ: The administrative dental assistantThe administrative dental assistant, Philadelphia, 2006, Saunders.), Philadelphia, 2006, Saunders.)


Medical-Alert Information Medical-Alert Information

Note to the dental healthcare team of medical Note to the dental healthcare team of medical conditions, allergic reactions, and conditions, allergic reactions, and medications that could interfere with dental medications that could interfere with dental treatment or be life-threatening to the patienttreatment or be life-threatening to the patient Place an alert sticker on the inside of the patient’s Place an alert sticker on the inside of the patient’s

record. record.


Fig. 26-6 Examples of medical-alert stickers.Fig. 26-6 Examples of medical-alert stickers.(Courtesy of SYCOM, Madison, Wis)(Courtesy of SYCOM, Madison, Wis)


Health-History UpdateHealth-History Update

The patient must update his or her medical-The patient must update his or her medical-dental health history at every appointmentdental health history at every appointment

Health information that may have changed:Health information that may have changed: Diagnosis of medical conditionsDiagnosis of medical conditions MedicationsMedications


Fig. 26-7 Example of the medical-dental health-history-update form. Fig. 26-7 Example of the medical-dental health-history-update form. (From Gaylor LJ: (From Gaylor LJ: The administrative dental assistantThe administrative dental assistant, ed 2,St Louis, 2006, Saunders.), ed 2,St Louis, 2006, Saunders.)


Clinical-Examination Form Clinical-Examination Form

Provides the dental team with past, present, and Provides the dental team with past, present, and future examination, analysis, and charting needs future examination, analysis, and charting needs of the patient: of the patient: Patient’s name and date of examinationPatient’s name and date of examination Charting of existing restorations and present Charting of existing restorations and present

conditionsconditions Charting of periodontal conditionsCharting of periodontal conditions Patient’s chief complaintPatient’s chief complaint Findings of occlusal evaluationsFindings of occlusal evaluations Findings of temporomandibular joint evaluationsFindings of temporomandibular joint evaluations Comments Comments


Fig. 26-8 Clinical-examination form.Fig. 26-8 Clinical-examination form. (From Gaylor LJ: (From Gaylor LJ: The administrative dental assistantThe administrative dental assistant, Philadelphia, 2006, Saunders.), Philadelphia, 2006, Saunders.)


Treatment-Plan Form Treatment-Plan Form

This form is sequenced to address all This form is sequenced to address all problems identified during the examination problems identified during the examination and diagnosis portion of the patient visit. and diagnosis portion of the patient visit.


Fig. 26-9 Example of a treatment-plan form.Fig. 26-9 Example of a treatment-plan form. (From Gaylor LJ: (From Gaylor LJ: The administrative dental assistantThe administrative dental assistant, Philadelphia, 2006, Saunders.), Philadelphia, 2006, Saunders.)


Progress-Notes Form Progress-Notes Form

Treatment is recorded in this section of the Treatment is recorded in this section of the patient record.patient record.

Always include:Always include: DateDate Tooth numberTooth number Completed treatmentCompleted treatment SignatureSignature


Fig. 26-10 Example of a progress-notes form. Fig. 26-10 Example of a progress-notes form. (From Gaylor LJ: (From Gaylor LJ: The administrative dental assistantThe administrative dental assistant, Philadelphia, 2006, Saunders.), Philadelphia, 2006, Saunders.)


Informed-Consent Form Informed-Consent Form

This form, related to a specific treatment or This form, related to a specific treatment or procedure, provides the patient with the procedure, provides the patient with the expected outcomes of treatment and expected outcomes of treatment and describes any possible complications that describes any possible complications that might occur. might occur. Commonly used for invasive or extensive Commonly used for invasive or extensive

treatment, such as in specialty procedures.treatment, such as in specialty procedures.


Fig. 26-11 Example of the informed-consent form. Fig. 26-11 Example of the informed-consent form. (From Gaylor LJ: (From Gaylor LJ: The administrative dental assistantThe administrative dental assistant, Philadelphia, 2006, Saunders.), Philadelphia, 2006, Saunders.)


the patient record chapter 26 copyright © 2009, 2006 by saunders, an imprint of elsevier inc. all...

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patient record chapter

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patient record risk

active patient documentation

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critical information

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