 The patient record or clinical record is the principal document containing critical information you will need to manage each patient in the dental practice.  It is an accumulation of information that is gathered through a clinical, radiographic, photographic examination, and also includes all written forms and correspondence about the patient

 What is HIPAA:  HIPAA: the Health Insurance Portability and Accountability Act of 1996  All dental offices must have a privacy policy  The office will not use or disclose protected health information (PHI) for any purpose other than treatment, diagnosis and billing  Signed form that privacy policy was disclosed  Before dental treatment, the dental team must have the following information:  Patient registration  Medical-dental health history  Medical-alert information

 Permanent record  Personal and legal documentation of the patient  Can be used during a court case  All entries must be in ink and legible  No white out or scribbling over incorrect information  One single line in ink through incorrect entry  Initial any changes  Quality assurance  Primary source of information used by the dental team to determine the overall quality of care the patient has received.

 Risk management  The patient record provides documentation of the patient’s condition, diagnoses, and treatment and the patient’s responses to treatment.  Research/ Identification  The patient record provides a source of data for research purposes. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Key Terms:  Diagnosis:  translation of the data into organized definitions of conditions present  Prognosis:  a forecast of the probable course of a disease or condition  Respondeat Superior:  person legally responsible for actions which take place within the dental office  Sound dental care begins with a thorough examination of the head, neck and oral cavity Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

 As a new patient  For an emergency or a specific problem  For consultation with a specialist  As a returning patient for continued care Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

 All information obtained may be relayed to Doctor via a note instead of verbally to avoid alarming the patient  General Conditions:  Is there any facial asymmetry?  Skin color, eye color doesn’t belong with patient  Slow or difficult gait  Offensive breath odor  Difficulty breathing  Dilation of pupils  Withdrawn personality  Color of nail bed

 This assessment should be done at initial visit to establish a baseline for the patient and at least annually during their PMC (Preventive Maintenance Care)  This varies from office to office. At a minimum blood pressure should be taken  Vital signs:  Temperature- degree of heat of a living body  Pulse-the rate of blood traveling through the arteries  Respiration- the rate of oxygen intake  Blood pressure – pressure in the arteries at the height of pulse wave

Components:  Asymmetry, lesions, swelling or discoloration are noted  Drooping eyelids or lips, prominence of neck or eyes  Inspection of skin of face and neck, note any lesions  Examine the lymph nodes, includes size, shape and mobility. There should be no tenderness  Examine the TMJ; any tenderness, popping, clicking or crepitus  Recording of information must be accurate and thorough  Information is gathered by visual inspection and palpation  Palpation is to use the sense of touch to denote consistency or tenderness  An assistant must listen carefully not to miss any information being noted by the doctor

 Includes both extraoral and intraoral assessments  Extraoral features  Face, neck, tissue changes, skin abrasions, lips  Cervical lymph nodes  Temporomandibular joint  Oral habits  Intraoral features  Interior of the lips  Oral mucosa  Tongue  Floor of the mouth Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

 Includes all soft oral tissues, the periodontium, the teeth and their bite relationship  Examination for any lesions or changes in any soft tissue  Periodontium exam includes assessment of gingiva, cementum, periodontal ligament and the alveolar bone, mobility of teeth, furcation involvement and periodontal pocket depth would be determined  Teeth would be examined for existing restorations, existing missing teeth and all treatment needed  Bite relationship exam includes evaluating how a patient opens, closes and laterally moves the arches to determine if there are any abnormalities, check for overbite, overjet and openbite.  These exams are both visual and tactile

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

 Radiography, both intraoral and extraoral, provides indispensable tools for identifying:  Decay  Defective restorations  Advanced periodontal conditions  Pathologic conditions  Developmental conditions  Abnormalities Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

 Intraoral imaging allows the use of a video system:  To magnify an image for better evaluation  For easier access to difficult areas  For photocopying images for insurance purposes  For case simulation or presentation  For medical and legal documentation

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

 Intraoral and extraoral photography  Provides a visual means of identifying and understanding specific problems..

 Specific criteria that must be known before charting:  Black classification of cavities  Tooth diagrams  Tooth-numbering systems  Color coding  Charting symbols

 Geometric  Anatomical

 Specific periodontal findings to be recorded:  Overall health condition of gingiva  Signs and location of inflammation  Location and amount of plaque and calculus  Areas of unattached gingiva  Areas of periodontal pockets larger than 3 mm  Presence of furcation involvement  Dental mobility scale Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

 Levels of care  Level I, emergency care, relieves immediate discomfort.  Level II, standard care, restores the patient to normal function.  Level III, optimum care, restores the patient to maximum function  Presentation of treatment plan  Recording of dental treatment Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

 Information-gathering  Address the patient, using his or her surname.  Give the reason for obtaining the information.  Answer any questions the patient may have. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

 Patient information: full name, date of birth, residence, phone number, employment, spouse’s information  Insurance information: employee’s name and date of birth; employer’s name, address, and phone number; name of insurance carrier and policy number  Responsible party: person responsible for payment of the account  Signature and date: verifies the accuracy of information Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

 Medical-history section  Questions regarding the patient’s medical history, present physical condition, chronic conditions, allergies, and medications currently being taken  Dental-history section  Information about the patient’s previous dental treatment and care and how the patient feels about dentistry and how important dental care is to him or her Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

 Note to the dental healthcare team of medical conditions, allergic reactions, and medications that could interfere with dental treatment or be life-threatening to the patient  Place an alert sticker on the inside of the patient’s record. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

 The patient must update his or her medical- dental health history at every appointment  Health information that may have changed:  Diagnosis of medical conditions  Medications  Signed and dated Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

 Provides the dental team with past, present, and future examination, analysis, and charting needs of the patient:  Patient’s name and date of examination  Charting of existing restorations and present conditions  Charting of periodontal conditions  Patient’s chief complaint  Findings of occlusal evaluations  Findings of temporomandibular joint evaluations  Comments Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

 This form is sequenced to address all problems identified during the examination and diagnosis portion of the patient visit. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

 Treatment is recorded in this section of the patient record.  Always include:  Date  Tooth number  Completed treatment  Signature Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

 This form, related to a specific treatment or procedure, provides the patient with the expected outcomes of treatment and describes any possible complications that might occur.  Commonly used for invasive or extensive treatment, such as in specialty procedures. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

 Always in black ink (MDA) some offices color code by entry type  Black – dentist treatment  Red – hygienist treatment  Green – financial entry  Always date  Document procedures and all pertinent information clearly and concisely  Always sign entry to confirm accuracy  Never white out or cross out making entry unreadable  One single line in ink through incorrect entry