Dental Records and Patient Information Quiz

Learning and Performance Outcomes

• Students will be able to define, pronounce, and spell key terms related to patient dental records.
• Students will understand the patient dental record, its legal implications, and how dentists use it to manage treatment.
• Students will define personal health information (PHI) and how it's categorized under HIPAA.
• Students will be able to describe electronic dental record usage and the benefits of going paperless.
• Students will be able to list and explain the components of a patient record and their significance.
• Students will manage new patient registration forms.
• Students will obtain completed medical-dental health history forms for new patients.
• Students will record complete dental treatment information.
• Students will demonstrate record correction procedures on paper records.

Key Terms

• alert: to bring attention to a specific medical or clinical condition.
• assessment: the process of collecting data and evaluating findings.
• chronic: persisting over a long time.
• chronologic: arranged according to the time of occurrence (earliest to latest).
• demographics: personal information like address, phone, and work details, and population statistics.
• forensic: scientific methods used in crime investigation.
• litigation: initiating legal action, such as a lawsuit.
• quality assurance: a program for monitoring and evaluating the quality of a project or service.
• registration: providing personal information to complete forms.

Dental Record

• The dental record is the most important document for each patient.
• The record is needed for communication with patients, pharmacies, insurance companies, and specialists.
• Sections of the record include registration, medical/dental histories, clinical examination, radiographs, progress notes, prognosis notes, treatment records, referrals, and prescriptions.
• The record is a permanent legal document, used as evidence in legal proceedings or by third parties.
• Dental records contain personal health information (PHI), which is protected under HIPAA.

Privacy

• Dental records include confidential information on patient health, personal, and financial details.
• Proper documentation and handling of dental records are crucial.
• HIPAA governs personal health information (PHI) under the Health Information Portability and Accountability Act.

Quality Assurance

• The patient record serves as a primary source for assessing patient care quality.
• The key is to determine if the patient believes the timeliest and best treatment is provided.
• Practices should include routine forms completion (signed & dated) for quality procedures, on-time patient recalls, and thorough record documentation.

Risk Management

• The dental record documents clinical findings, diagnoses, treatment plans, and patient responses.
• This record is important for practices when litigation or malpractice arises.

Electronic Dental Record (EDR)

• Electronic dental records are used in over 70% of modern dental practices.
• EDRs enable storing, retrieving, importing, and exporting information digitally.
• EDRs are more user-friendly, allowing for efficient management of patient records.

Patient Forms

• Various forms are used for information gathering, completed before any treatment.
• Examples include patient registration, medical-dental health history, medical alerts, and consent forms.

Diagnostic Information

• Physical and communication skills are documented in the medical history.
• Radiographic (periapical, bitewing, occlusal, panoramic) examinations.
• Clinical examination gathers intraoral and extraoral information and helps with diagnosis.
• Dental assessment from clinical findings completes a patient's oral health profile.

Clinical Examination and Treatment

• Detailed clinical examination and recall information, including analysis, and charting, is recorded in dental records.
• Treatment plans incorporate identified problems and are documented.
• Consent forms are completed for any major treatment plan.
• Progress notes from procedures are made and signed.

Legal and Ethical Implications

• Patient records are highly confidential documents.
• They are used as evidence in legal cases and must follow legal and ethical standards.
• Information in records must remain private and not shared without patient authorization.