DOCUMENTATION OF PATIENT’S RECORD NORZAFIRAH KASSIM MASYITAH MUSTAFFA

DEFINITION DOCUMENTATION is defined as the material that provides official information or evidence that serves as a record. also can be describe as the process of classifying and annotating texts, photographs, etc.

DENTAL RECORD patient’s folders, cards or charts contain all the information about the patient’s history, investigation done to the patients and also all the treatments that had be done to the patients records all the important communication between the patients and dental practitioners in the dental clinic

BASIC PERSONAL INFORMATION DIAGNOSTIC INFORMATION TREATMENT PLAN NOTES DENTAL RECORD BASIC PERSONAL INFORMATION DIAGNOSTIC INFORMATION TREATMENT PLAN NOTES TREATMENT PERFORMED INFORMED CONSENT PATIENT RELATED COMMUNICATION INSTRUCTION FOR HOME CARE

IMPORTANCE sign of quality best possible care for the patient communication between the treating dentist and the patient’s future dentist Defense of allegations of malpractice Forensic odontology

Organization Of Dental Record (Filing System) Traditional filing system Computerized/electronic filing system

Government Dental Clinic Cards

computerized filling systems (E-clinical) Confidentiality Integrity Accessibility Adv, disadv

Content of Dental Record database information (name, IC number, birth date, address, occupation and contact information) Chief Complaint and history of chief complaint Medical, dental, social histories and habits Intra-oral and extra-oral examination Diagnostic and investigation records, including charts, study models and radiographs conversations about any proposed treatment potential benefits and risks alternatives treatment treatment plan notes medication prescriptions Types, dose, amount directions for use and number of refills Treatment done to the patient

laboratory work order forms mold and shade of teeth used in bridgework and dentures and shade of synthetics and plastics referral letters and consultations with referring or referral dentists and/or physicians patient noncompliance and missed appointment notes follow-up and periodic visit records postoperative or home instructions (or reference to pamphlets given) consent forms waivers and authorizations conversations with patients dated and initialed (both in-office and on telephone, even calls received outside the office) correspondence, including dismissal letter; if appropriate

How to write in a record Document the record while patient still in the clinic or as soon as patient leaves All entries should be dated, initialed and handwritten in ink and/or computer printed Easy to be read Any attachment be include in the record eg; radiograph, informed consent etc If patient refuse to accept the recommended treatment plan, notate the reason

Use only common abbreviation. Simply cross out any correction that need to be done and not obliterate an entry. Every correction must have initial and date. No blank lines between entries.

Consequences of error in dental record Prevent professional liability insurance companies to successfully defending dentists against unfounded allegations of malpractice Allegation – a claim of fact by a party in a pleading which the party claim to be able to prove. (dakwaan)

Conclusion Documentation of dental record is vey important. It benefit both patients and dentists. Dental record is a legal document that cannot be neglected.