Copyright 2003, Elsevier Science (USA). All rights reserved. Chapter 26 The Patient Record Copyright 2003, Elsevier Science (USA). All rights reserved. No part of this product may be reproduced or transmitted in any form or by any means, electronic or mechanical, including input into or storage in any information system, without permission in writing from the publisher. PowerPoint ® presentation slides may be displayed and may be reproduced in print form for instructional purposes only, provided a proper copyright notice appears on the last page of each print-out. Produced in the United States of America ISBN

Copyright 2003, Elsevier Science (USA). All rights reserved. Introduction The patient record is the principal document of information that you will manage for each patient in your dental practice.

Copyright 2003, Elsevier Science (USA). All rights reserved. The Function of the Patient Record  Permanent record is a personal and legal document of the dentist.  Quality assurance: Primary source of information to determine the overall quality of care the patient has received.  Permanent record is a personal and legal document of the dentist.  Quality assurance: Primary source of information to determine the overall quality of care the patient has received.

Copyright 2003, Elsevier Science (USA). All rights reserved.  Examples of quality assurance Routine forms completed by each patient. Timely recall of patients for their dental needs. Completed patient record for each “active” patient. Documentation of when radiographs are taken. Current and up-to-date emergency standards maintained by the dental team. Current and up-to-date licenses, registrations, and training.  Examples of quality assurance Routine forms completed by each patient. Timely recall of patients for their dental needs. Completed patient record for each “active” patient. Documentation of when radiographs are taken. Current and up-to-date emergency standards maintained by the dental team. Current and up-to-date licenses, registrations, and training. The Function of the Patient Record  cont’d

Copyright 2003, Elsevier Science (USA). All rights reserved.  Risk management Documentation regarding the patient’s condition, diagnoses, treatment, and the patients responses to treatment.  Research The patient record provides a source of data for research purposes.  Risk management Documentation regarding the patient’s condition, diagnoses, treatment, and the patients responses to treatment.  Research The patient record provides a source of data for research purposes. The Function of the Patient Record  cont’d

Copyright 2003, Elsevier Science (USA). All rights reserved. Getting To Know Your Patient  Information Gathering Address the patient, using his or her surname. Give the reason for obtaining the information. Answer any questions the patient may have.  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 2003, Elsevier Science (USA). All rights reserved. Components of the Patient Record  Patient registration form Patient information Insurance information Responsible party Signature and date  Patient registration form Patient information Insurance information Responsible party Signature and date

Copyright 2003, Elsevier Science (USA). All rights reserved. Fig Patient registration form.

Copyright 2003, Elsevier Science (USA). All rights reserved. Medical-Dental Health History Form  Medical history section Questions regarding the patient’s past medical history, present physical condition, chronic conditions, allergies, and medications that are currently being taken.  Dental history section Gains information about the patient’s previous dental treatment and care, and their feelings toward dentistry and how important dental care is to them.  Medical history section Questions regarding the patient’s past medical history, present physical condition, chronic conditions, allergies, and medications that are currently being taken.  Dental history section Gains information about the patient’s previous dental treatment and care, and their feelings toward dentistry and how important dental care is to them.

Copyright 2003, Elsevier Science (USA). All rights reserved. Fig Medical-dental health history form.

Copyright 2003, Elsevier Science (USA). All rights reserved. Medical Alert Information  Note to the dental health team of medical alerts or other precautions that need to be followed in providing safe care to that patient.

Copyright 2003, Elsevier Science (USA). All rights reserved. Fig Medical-dental health history update form.

Copyright 2003, Elsevier Science (USA). All rights reserved. Clinical Examination Form  Provides the dental team with past, present, and future examination, analysis, and charting needs of the patient.

Copyright 2003, Elsevier Science (USA). All rights reserved. Fig Clinical examination form.

Copyright 2003, Elsevier Science (USA). All rights reserved. Treatment Plan Form  Sequenced to address all problems identified during the examination and diagnosis portion of the patient visit.

Copyright 2003, Elsevier Science (USA). All rights reserved. Fig Treatment plan form.

Copyright 2003, Elsevier Science (USA). All rights reserved. Progress Notes Form  Section of the patient record where treatment is recorded.  Always include: Date Tooth number Completed treatment Signature  Section of the patient record where treatment is recorded.  Always include: Date Tooth number Completed treatment Signature

Copyright 2003, Elsevier Science (USA). All rights reserved. Fig Progress notes form.

Copyright 2003, Elsevier Science (USA). All rights reserved. Informed Consent Form  Provides the patient with what they should expect as an outcome of treatment, and describes any possible complications that might occur.

Copyright 2003, Elsevier Science (USA). All rights reserved. Fig Informed consent form.