Podcast
Questions and Answers
What type of information should be included in the identification data of an oral health record?
What type of information should be included in the identification data of an oral health record?
- Clinical examination and diagnosis
- Medical history and dental history
- Patient full name, address, and telephone number, age, sex, and occupation (correct)
- Documentation of informed consent and progress notes
What is the primary purpose of the diagnosis stage in the oral health process?
What is the primary purpose of the diagnosis stage in the oral health process?
- To make a judgment of variations from normal (correct)
- To initiate treatment planning
- To document patient information
- To determine the patient's chief complaint
Why is it essential to determine the patient's chief complaint?
Why is it essential to determine the patient's chief complaint?
- To understand the problem that initiated the patient's visit (correct)
- To initiate treatment immediately
- To document patient information
- To plan for future appointments
What is the primary goal of infection control measures in oral healthcare?
What is the primary goal of infection control measures in oral healthcare?
What is the purpose of the barrier technique in oral healthcare?
What is the purpose of the barrier technique in oral healthcare?
What should a recording chart in oral healthcare be?
What should a recording chart in oral healthcare be?
What is the primary purpose of discussing the patient's current problem, including onset, duration, symptoms, and related factors?
What is the primary purpose of discussing the patient's current problem, including onset, duration, symptoms, and related factors?
What type of condition may be identified during a medical review, requiring special precautions to prevent cross infection?
What type of condition may be identified during a medical review, requiring special precautions to prevent cross infection?
What is the primary purpose of a dental history, including past and present dental history?
What is the primary purpose of a dental history, including past and present dental history?
What is the first step in examining the oro-facial soft tissue during a clinical examination?
What is the first step in examining the oro-facial soft tissue during a clinical examination?
What is caries risk assessment defined as?
What is caries risk assessment defined as?
What is the purpose of a clinical examination in a clean, dry, well-illuminated mouth?
What is the purpose of a clinical examination in a clean, dry, well-illuminated mouth?
Study Notes
Oral Health Record
- Includes identification data, medical history, dental history, clinical examination, diagnosis, treatment planning, and documentation of informed consent, progress notes, and completion notes.
Recording Chart
- Should be uncomplicated, comprehensive, accessible, and current.
- Uncomplicated: easily understood by the patient.
- Comprehensive: notes all conditions, both normal and abnormal.
- Accessible: can be easily reached for treatment or real appointments.
- Current: can accept any changes in treatment.
Examination and Diagnosis
- Examination: observing both normal and abnormal conditions.
- Diagnosis: determination and judgment of variations from normal.
Patient Assessment
- Infection control: instituted before, during, and after patient visits, including barrier technique and proper use of disinfectants and instrument sterilization.
- Chief complaint: determining the patient's primary problem, including onset, duration, symptoms, and related factors.
- Medical review: identifying conditions that may complicate or contraindicate dental procedures, including:
- Communicable diseases (e.g., hepatitis)
- Allergies (e.g., to penicillin or local anesthesia)
- Medications (e.g., anticoagulants)
- Systemic diseases and cardiac abnormalities
- Physiologic changes associated with aging
- Dental history: including past and present dental history, indicating patient motivation and future behavior.
Clinical Examination
- Performed in a clean, dry, well-illuminated mouth using diagnostic instruments (e.g., mirror, explorer, periodontal probe).
- Includes examination of:
- Oro-facial soft tissue
- Caries lesions
- Non-carious lesions
- Existing restorations
- Periodontium
- Occlusion
- Examination of patient in pain
Examination of Oro-Facial Soft Tissue
- Begins with examination of:
- Submandibular glands and cervical lymph nodes for abnormalities
- Masticatory muscles for pain or tenderness
- Visual examination and palpation of cheeks, vestibules, mucosa, lips, lingual and facial alveolar mucosa, palate, tonsillar areas, tongue, and floor of the mouth
Diagnosis of Dental Caries
- Caries risk assessment: probability of new lesions developing or existing lesions progressing over time.
- Identification of caries: diagnosed using traditional examination modalities, including:
- Visual examination using a mirror
- Examination of tooth surface texture or color changes
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Description
This quiz covers the essential information to be included in an oral health record, including patient identification data, medical and dental history, clinical examination, and treatment planning. It also outlines the proper format for recording charts.
