Copyright 2003, Elsevier Science (USA). All rights reserved.
Chapter 26The Patient Record
Chapter 26The Patient Record
Copyright 2003, Elsevier Science (USA).
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ISBN 0-7216-9770-4
Copyright 2003, Elsevier Science (USA). All rights reserved.
IntroductionIntroduction The patient record is the principal
document of information that you will manage for each patient in your dental practice.
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 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 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 The Function of the Patient Record cont’d
Copyright 2003, Elsevier Science (USA). All rights reserved.
Getting To Know Your Patient 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 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. 26-3 Patient registration form. Fig. 26-3 Patient registration form.
Copyright 2003, Elsevier Science (USA). All rights reserved.
Medical-Dental Health History Form 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. 26-4 Medical-dental health history form. Fig. 26-4 Medical-dental health history form.
Copyright 2003, Elsevier Science (USA). All rights reserved.
Medical Alert Information 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.
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. 26-6 Medical-dental health history update form. Fig. 26-6 Medical-dental health history update form.
Copyright 2003, Elsevier Science (USA). All rights reserved.
Clinical Examination Form Clinical Examination Form
Provides the dental team with past, present, and future examination, analysis, and charting needs of the patient.
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. 26-7 Clinical examination form. Fig. 26-7 Clinical examination form.
Copyright 2003, Elsevier Science (USA). All rights reserved.
Treatment Plan Form Treatment Plan Form
Sequenced to address all problems identified during the examination and diagnosis portion of the patient visit.
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. 26-9 Treatment plan form. Fig. 26-9 Treatment plan form.
Copyright 2003, Elsevier Science (USA). All rights reserved.
Progress Notes Form 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. 26-10 Progress notes form.Fig. 26-10 Progress notes form.
Copyright 2003, Elsevier Science (USA). All rights reserved.
Informed Consent Form Informed Consent Form
Provides the patient with what they should expect as an outcome of treatment, and describes any possible complications that might occur.
Provides the patient with what they should expect as an outcome of treatment, and describes any possible complications that might occur.