Treatment Note must be entered for every patient visit
Every question must be answered in the medical history Changes in medications must be noted in the medical history BP, Pulse in Medical summary page Get medical history signed if there are any changes
Complete records are vital part of providing comprehensive care for the patient Medical history- updated and signed Record existing restorations, conditions, perio charting accurately Treatment notes at every visit Timely entry of complete treatment notes Cannot change the date of note entry Change the planned treatments to complete
Medical History-updated and signed Medical Hold? Release letter attached? Approvals by faculty? Oral exam completed and approved? Radiographs recorded and readable? Treatment note for every visit? Complete notes? Abnormal reactions, anesthesia, etc.? Is TP being carried out in reasonable time? If not, are there contact notes to explain why?
Assigned patients from your mini-clinic by your PCC Open the patient record in axium Complete the survey on paper first Open the survey in patient record in axium Complete the electronic survey with answers recorded on your sheet
Click on Tools- top toolbar- Survey- Category- drop down arrow Choose QA2 Chart Audit Form Complete the answers Return survey forms to K Hansel by Friday, April 19 th Must also be completed in the patient’s chart by this date