The Patient's Dental Record PDF

26 The Patient’s Dental Record L E A R N I N G A N D P E R F O R M A N C E O U TCO M E S Learning Outcomes On completion of this chapter, the student will be able to achieve the following objectives: 1. Pronounce, define, and spell the key terms. 5. Provide the component...

26 The Patient’s Dental Record L E A R N I N G A N D P E R F O R M A N C E O U TCO M E S Learning Outcomes On completion of this chapter, the student will be able to achieve the following objectives: 1. Pronounce, define, and spell the key terms. 5. Provide the components of a patient record and their 2. Explain the patient dental record, its legal significance, importance: and how the dentist uses the record to manage patient atient registration treatment. edical dental health history 3. Define personal health information (PHI) and what is considered Clinical examination PHI under HIPAA law. Treatment plan 4. Describe how electronic records are used in a dental practice Informed consent and the benefits of going paperless. rogress notes Performance Outcomes On completion of this chapter, the student will be able to achieve the following objectives: 1. Oversee the completion of a new patient registration form. 3. Enter the information for a completed dental treatment.. btain a completed medical dental health history form for a 4. Demonstrate how to make corrections on a patient’s record new patient. when using a paper version. KEY TERMS alert to bring attention to a specific medical or clinical condition forensic (fuh-REN-zik) scientific methods and techniques used to assessment the process of collecting data and evaluating or identify a person of interest or to investigate a crime drawing conclusions from the findings litigation (li-ti-GAY-shun) act of initiating legal proceedings, as in chronic persisting over a long time a lawsuit chronologic arranged according to the time of occurrence; quality assurance program in place for monitoring and earliest to most recent evaluating a project, service, or facility to ensure that standards demographics personal information that can include address, phone, of quality are being met and work information; also, statistical characteristics of populations registration act of completing forms by providing personal diagnosis identification or determination of an illness, disease, or information injury by examination of the patient’s history and symptoms T he dental record is the most important document maintained used as (1) evidence in a legal settlement or lawsuit; (2) as a reference for each patient in a dental practice (Fig. 26.1). Whether for appropriate third parties, such as dental insurance companies you are communicating with a patient by phone or in and government-aided programs; or (3) as a reference tool in a person, speaking to a pharmacy about a prescription, talking to an forensic case for evidence in identifying an individual with the insurance company regarding treatment, or referring a patient to a use of radiographs or study casts. specialist, the patient dental record must be available for reference. The dental record consists of several sections: the registration Privacy form, medical and dental history, clinical examination form, radio- graphs, progress notes, notes on prognosis, treatment completed, A dental record contains confidential information related to a referral letters, drug prescriptions, and laboratory prescriptions. patient’s personal, health, and financial background. It is important for the dental team to follow a standard when documenting and Permanent Record handling a dental record. This standard is referred to as personal health information (PHI), which originates under the Health The dental record is a permanent document of the dentist. This Information Portability and Accountability Act (HIPAA) privacy permanent document, also considered a legal document, can be rule, discussed in Chapter 5. 360  CHAPTER 26 The Patient’s Dental Record 361 Fig. 26.1 Example of the patient record electronic form. (Courtesy Henry Schein Practice Solutions, American Fork, UT.) There are two areas of PHI as related to the patient dental receives. Quality is the key word to remember when a patient is record, as follows: receiving dental care. Personal information, which includes the following identifiers: Does the patient think the best and timeliest treatment is being name, date of birth, gender, ethnicity, emergency contact provided? This question can be particularly important if the clinical information, address, phone numbers, email, health insurance, setting is a larger practice with multiple practitioners, a community and financial accounts dental clinic, or a teaching institution in which patients may be Health information such as diagnosis, treatment, laboratory seen by different dentists and clinical professionals. Each dental results, and prescription information setting must promote an efficient and effective quality assurance HIPAA enforces that physical, technical, and administrative program. The following examples are ways to provide quality safeguards must be implemented. Examples of this include encryp- assurance in your dental office: tion of software, firewalls on all computers, and all paper records Routine forms are completed for each patient and verified with and electronic devices maintained under lock and key. All staff his or her signature and date. who have access to PHI are to complete security awareness Timely “recall” of patients is followed to address their dental training. needs. HIPAA requires that all dental practices today have a written A completed dental record is kept for each “active” patient in privacy policy. This written policy must inform the patient that the dental practice. the office will not use or disclose protected health information for Documentation includes information when radiographs are any purpose other than treatment, diagnosis, and billing. The taken. privacy policy is prepared in a written format and must be provided Current and up-to-date emergency protocols are adhered to by to every patient to review and sign an acknowledgment that they the dental team. have received notice of privacy practices. This signed acknowledg- Current and up-to-date licenses, registrations, certifications, ment is kept in the patient’s record for a minimum of 6 years. and training of dental team members are maintained. Quality Assurance Risk Management The dentist will use the patient record as the primary source of As noted earlier, the dental record provides documentation regarding information in determining the overall quality of care a patient a patient’s clinical findings, diagnosis, treatment plan, and response 362 PART 6 Patient Information and Assessment to treatment. For the dentist to avoid litigation such as a malpractice Once the preliminary information is gathered, the business suit in the process or outcome of treating a patient, patient records assistant will either prepare the dental record in paper form or must be kept organized and complete. enter the information into the electronic patient record and alert the clinical staff that the patient is ready to be escorted to the clinical setting. Research A complete and chronologic order of a dental record or of a Patient Registration specific dental condition that has been diagnosed can provide data to be used for research purposes. In an educational or public health The patient registration form contains information related to patient setting, patients may be asked to participate in a research study. demographics and financial responsibility (Fig. 26.2). The patient When a new research study begins, the steps taken to inform the is asked to provide the following information on the registration patient and to clarify all steps in patient treatment or in the specific form (see Procedure 26.1: Registering a New Patient): use of a new dental product must be accurately documented. If Patient information: Full name, date of birth, address, email documentation is not complete, data could be eliminated from address, telephone numbers (home, cell, work), employment the study, which could affect the outcome and results. information, spousal information, and emergency contact (a patient’s Social Security number should no longer be included RECALL in this area because of the privacy act). Insurance information: Dental insurance company name and 1. The patient record is a permanent document for whom? policy number; name of employee; date of birth; and employer’s 2. How can quality assurance affect a patient’s dental care? 3. PHI is the abbreviation for what? name, address, and telephone number. Many practices will ask the patient for his or her insurance card to make a copy for their records. Electronic Dental Record Responsible party: Person responsible for payment of the account (patient, spouse, parent, or legal guardian). Today, more than 70% of dental practices have integrated some Signature and date: The patient verifies the accuracy of the aspect of the electronic dental record (EDR) into their daily produc- information. tion. This type of system parallels the electronic health record (EHR) from the medical community. The software is designed to Medical-Dental Health History capture, store, present, import, and export relevant information from a patient’s personal and clinical record. The patient must complete a medical-dental health history form For most dental practices today, the benefits of going paperless (Fig. 26.3; Procedure 26.2: Obtaining a Medical-Dental Health include the following: History). The health history form should be regarded as minimal Accessing the dental record safeguarded in many locations of information from a patient. The responsibility of the dental team the office is to review the form, initiate conversation, and ask questions Performing practice management tasks such as patient registra- to gain greater insight into the patient’s well-being. Once the tion, scheduling, billing, and inquiry about an insurance status form has been completed, the adult patient who completed the Allowing the dental team to enter relevant clinical documenta- form or the patient’s legal guardian must sign and date the form tion, charting, completing a laboratory prescription, and to confirm that the information is correct. The health history electronically prescribing medication form is divided into medical assessment and dental assessment Sharing health information with authorized providers across sections. more than one healthcare organization The dentist and the office manager will decide on the type of Medical History software and the design of the forms to be used and the order in The medical history section includes questions regarding the patient’s which they are to be assembled and accessed. Each staff member medical history, present physical conditions, chronic conditions, must learn this sequence to ensure all materials are accessible and allergies, and current medications. This information (1) alerts the can be easily found. dentist to possible medical conditions and medications that could complicate or interfere with dental treatment, (2) aids the dentist Patient Record Forms in anticipating any potential medical emergencies based on the patient’s medical background, and (3) identifies special treatment Information-gathering forms are to be completed by the patient needs that a patient may require. before any treatment is provided. It is common in dental practices If specific medical conditions are a matter of concern to today that these forms are available for patients to complete either the dentist, the dentist will consult with the patient’s physician online before their scheduled appointment or by having the forms regarding treatment. The patient will be required to sign a release- downloaded onto an electronic tablet to complete on arrival to of-information form to give consent before a consultation can the office. take place. Examples of these types of forms include the following: Patient registration form (personal patient information) Dental History Medical-dental health history form (patient’s overall health and The dental history section of the form is used to obtain information dental status) about the patient’s previous dental treatment and care. By asking Medical alert information (any medical concerns that need to questions about oral home care and previous dental experiences, alert the dental team before treatment) the dental team can gain insight into the patient’s feelings toward Consent forms (HIPAA, verification of accuracy, insurance dentistry and information about the patient’s own dental care.  CHAPTER 26 The Patient’s Dental Record 363 PATIENT INFORMATION (please fill out and provide signature below) Patient’s Name: ______________________________________ Date: _______ Last, First MI Mailing Address: ________________________________________________________ Street Apartment # _______________________________________________________________ City State Zip Code Phone Numbers: Cell: ________________ Home: _______________ Work: _______________ Best time to call: ____________ Send Text Message: _____________ am / pm yes / no Email: ____________________________ **HIPAA**: Do we have permission to leave appointment, billing or dental information on your answering machine, voicemail or e-mail at the numbers listed above: yes / no ______________ Do You Need Communication Assistance? yes / no _____ If yes, please explain __________________ RESPONSIBLE PARTY / GUARANTOR INFORMATION Please complete only if; parent / legal guardian / spouse is responsible for this account Name: ___________________________________________________________________ Relationship to Patient: Parent ___, Legal guardian ___ Spouse ____ Other ____ Address: _________________________________________________________ Street Apartment # ______________________________________________________________ City State Zip Code Phone Numbers: Cell: ____________ Home: ____________ Work: ____________ E-mail: _________________________________ Employer Name / Address: ____________________________________________________ Name Street City State Zip PRIMARY INSURANCE INFORMATION Name of Insured: ____________________ Insured Soc. Sec: _____________________ Relationship to Patient: Self____Spouse____Parent____other______ Insured Birth Date: _______ Ins. Company Name _______________________________________________________________ Address ____________________________________________ Phone # _____________________ Insurance ID# __________________________ Group ID # ________________________________ REFERRAL INFORMATION How did you learn about our dental office? Patient ___, Staff____, Family____, Friend____, Dental office ___, Website____, Newspaper____, other ________________ Signature (consenting to the above information) Signature of Patient/ Parent / Guardian____________________________________ DATE________ Reviewed by: __________________________________________ Date: __________________ Dentist / Office Manager Fig. 26.2 Example of a patient registration form. (Courtesy of Patterson Office Supplies, Inc.) Medical Alert In the dental record, medical alerts and other precautions should be entered so that safe care is provided to the patient. When you When you receive a completed medical-dental health history receive this information, an “alert” entry will be noted in the EDR. form, one of your first priorities is to review indications of If you are using paper forms, the alert sticker is to be placed inside health conditions, allergic reactions, and medications that could the record to maintain dentist/patient confidentiality. The alert interfere with or be life threatening to the patient during dental sticker should never be placed on the outside for others to see. treatment. An example of this would be a reaction to a specific antibiotic that could be prescribed for dental treatment. The Medical-Dental Health History Update dental team would inquire with further questions and make note with a listing of the antibiotic this patient cannot be prescribed Returning patients are to be asked to update their medical-dental (Fig. 26.4). health history at every appointment (Fig. 26.5). Even if a patient  Health History Form Email: Today’s Date: As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate. Name: Home Phone: Include area code Business/Cell Phone: Include area code Last First Middle ( ) ( ) Address: City: State: Zip: Mailing address Occupation: Height: Weight: Date of Birth: Sex: M F SS# or Patient ID: Emergency Contact: Relationship: Home Phone: Include area code Cell Phone: Include area code ( ) ( ) If you are completing this form for another person, what is your relationship to that person? Your Name Relationship Do you have any of the following diseases or problems: (Check DK if you Don’t Know the answer to the the question) Yes No DK Active Tuberculosis..................................................................................................................................................................................................................................................... Persistent cough greater than a 3 week duration..................................................................................................................................................................................................... Cough that produces blood........................................................................................................................................................................................................................................ Been exposed to anyone with tuberculosis............................................................................................................................................................................................................... If you answer yes to any of the 4 items above, please stop and return this form to the receptionist. Dental Information For the following questions, please mark (X) your responses to the following questions. Yes No DK Yes No DK Do your gums bleed when you brush or floss?................................................... Do you have earaches or neck pains?.................................................................. Are your teeth sensitive to cold, hot, sweets or pressure?................................ Do you have any clicking, popping or discomfort in the jaw?............................ Is your mouth dry?............................................................................................... Do you brux or grind your teeth?........................................................................ Have you had any periodontal (gum) treatments?............................................. Do you have sores or ulcers in your mouth?....................................................... Have you ever had orthodontic (braces) treatment?......................................... Do you wear dentures or partials?...................................................................... Have you had any problems associated with previous dental treatment?......... Do you participate in active recreational activities?........................................... Is your home water supply fluoridated?.............................................................. Have you ever had a serious injury to your head or mouth?.............................. Do you drink bottled or filtered water?............................................................... Date of your last dental exam: If yes, how often? Circle one: DAILY / WEEKLY / OCCASIONALLY What was done at that time? Are you currently experiencing dental pain or discomfort?..................... Date of last dental x-rays: What is the reason for your dental visit today? How do you feel about your smile? Medical Information Please mark (X) your response to indicate if you have or have not had any of the following diseases or problems. Yes No DK Yes No DK Are you now under the care of a physician?....................................................... Have you had a serious illness, operation or been hospitalized Physician Name: Phone: Include area code in the past 5 years?.............................................................................................. ( ) If yes, what was the illness or problem? Address/City/State/Zip: Are you taking or have you recently taken any prescription or over the counter medicine(s)?........................................................................ Are you in good health?....................................................................................... If so, please list all, including vitamins, natural or herbal preparations Has there been any change in your general health within the past year?.......... and/or dietary supplements: If yes, what condition is being treated? Date of last physical exam: © 2012 American Dental Association Form S500 A Fig. 26.3Example of a medical-dental health history form. (A) Dental history. (B) Medical history. (Copy- right 2012, American Dental Association. All rights reserved. Reprinted with permission.)  Medical Information Please mark (X) your response to indicate if you have or have not had any of the following diseases or problems. (Check DK if you Don’t Know the answer to the question) Yes No DK Yes No DK Do you wear contact lenses?............................................................................... Do you use controlled substances (drugs)?........................................................ Joint Replacement. Have you had an orthopedic total joint Do you use tobacco (smoking, snuff, chew, bidis)?............................................ (hip, knee, elbow, finger) replacement?.............................................................. If so, how interested are you in stopping? Circle one: VERY / SOMEWHAT / NOT INTERESTED Date: __________________ If yes, have you had any complications? __________________________ Do you drink alcoholic beverages?...................................................................... Are you taking or scheduled to begin taking an antiresorptive agent (like Fosamax®, Actonel®, Atelvia, Boniva®, Reclast, Prolia) for If yes, how much alcohol did you drink in the last 24 hours? _______________________________ osteoporosis or Paget’s disease?......................................................................... If yes, how much do you typically drink i n a week? _________________________________________ Since 2001, were you treated or are you presently scheduled to begin WOMEN ONLY Are you: treatment with an antiresorptive agent (like Aredia®, Zometa®, XGEVA) Pregnant?............................................................................................................. for bone pain, hypercalcemia or skeletal complications resulting from Number of weeks: ______________________ Paget’s disease, multiple myeloma or metastatic cancer?.................................. Taking birth control pills or hormonal replacement?........................................... Date Treatment began: _____________________________________________________________________ Nursing?............................................................................................................... Allergies. Are you allergic to or have you had a reaction to: Yes No DK To all yes responses, specify type of reaction. Yes No DK Metals _______________________________________________________________________________ Local anesthetics ___________________________________________________________________ Latex (rubber) ______________________________________________________________________ Aspirin _______________________________________________________________________________ Iodine ________________________________________________________________________________ Penicillin or other antibiotics _______________________________________________________ Hay fever/seasonal _________________________________________________________________ Barbiturates, sedatives, or sleeping pills __________________________________________ Animals ______________________________________________________________________________ Sulfa drugs __________________________________________________________________________ Food _________________________________________________________________________________ Codeine or other narcotics ________________________________________________________ Other ________________________________________________________________________________ Please mark (X) your response to indicate if you have or have not had any of the following diseases or problems. Yes No DK Yes No DK Yes No DK Artificial (prosthetic) heart valve......................................................................... Autoimmune disease............... Glaucoma................................ Previous infective endocarditis............................................................................ Rheumatoid arthritis............... Hepatitis, jaundice or Systemic lupus liver disease............................. Damaged valves in transplanted heart................................................................ erythematosus........................ Epilepsy................................... Congenital heart disease (CHD) Asthma.................................... Fainting spells or seizures....... Unrepaired, cyanotic CHD............................................................................ Bronchitis................................ Neurological disorders............ Repaired (completely) in last 6 months....................................................... If yes, specify:____________________________ Repaired CHD with residual defects............................................................ Emphysema............................. Sleep disorder......................... Sinus trouble........................... Except for the conditions listed above, antibiotic prophylaxis is no longer recommended Do you snore?......................... Tuberculosis............................. for any other form of CHD. Mental health disorders.......... Cancer/Chemotherapy/ Specify: __________________________________ Radiation Treatment................ Yes No DK Yes No DK Recurrent Infections............... Cardiovascular disease.......... Mitral valve prolapse............... Chest pain upon exertion........ Type of infection: _________________________ Angina.................................... Pacemaker............................... Chronic pain............................ Kidney problems...................... Arteriosclerosis...................... Rheumatic fever...................... Diabetes Type I or II............... Night sweats........................... Congestive heart failure........ Rheumatic heart disease......... Eating disorder........................ Osteoporosis........................... Damaged heart valves.......... Abnormal bleeding.................. Malnutrition............................ Persistent swollen glands Heart attack.......................... Anemia.................................... Gastrointestinal disease.......... in neck..................................... Severe headaches/ Heart murmur........................ Blood transfusion.................... G.E. Reflux/persistent migraines................................. If yes, date:_______________________________ heartburn................................ Low blood pressure............... Severe or rapid weight loss.... Hemophilia.............................. Ulcers...................................... High blood pressure............... Sexually transmitted disease.. AIDS or HIV infection.............. Thyroid problems.................... Other congenital Excessive urination................. heart defects......................... Arthritis................................... Stroke...................................... Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?...................................................................................................... Name of physician or dentist making recommendation: Phone: Include area code ( ) Do you have any disease, condition, or problem not listed above that you think I should know about?................................................................................................................ Please explain: NOTE: Both doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment. I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form. Signature of Patient/Legal Guardian: Date: Signature of Dentist: Date: FOR COMPLETION BY DENTIST Comments: B Fig. 26.3, cont’d 366 PART 6 Patient Information and Assessment Fig. 26.4 Examples of medical alert in an electronic patient record. (Dentrix screenshot courtesy Henry Schein Practice Solutions, American Fork, UT.) MEDICAL HISTORY UPDATE GENERAL HEALTH: EXCELLENT ____ GOOD ____ FAIR ____ POOR ____ YES ___ NO___ HAVE THERE BEEN ANY CHANGES IN YOUR HEALTH SINCE YOUR LAST DENTAL APPOINTMENT? IF YES, PLEASE DESCRIBE: __________________________________________________ __________________________________________________________________________ YES ___ NO ___ HAS THERE BEEN ANY CHANGES IN YOUR MEDICATIONS? IF YES, PLEASE DESCRIBE: ___________________________________________________________________________ ___________________________________________________________________________ YES ___ NO ___ IS THERE ANY REASON THAT RECEIVING DENTAL CARE MIGHT POSE A RISK TO YOU, OUR STAFF, OR OTHER PATIENTS? IF YES, PLEASE DESCRIBE: ___________________________________________________________________________ ___________________________________________________________________________ _______________________ _____________________________________________ Date Patient Signature _______________________ _____________________________________________ Date Dentist Signature Fig. 26.5 Example of the medical-dental health history update form.  CHAPTER 26 The Patient’s Dental Record 367 was seen by the dentist 2 weeks ago, the dentist may not be aware clinical examination form include the following (see Chapter 28 of any changes to a patient’s medication regimen or medical for detailed explanations of charting symbols): diagnosis if the history was not updated. A slight change in a Patient’s name and date of examination medical condition could cause a reaction when anesthesia or pain Charting system for existing restorations and present control methods are used by the dentist. The patient’s initial conditions medical-dental health history form should be given to the patient Charting system for periodontal conditions for review. If any changes are needed, a patient should record these Patient’s chief complaint on an additional form or on a separate line in the treatment section Occlusal evaluations of the patient record. The patient or parent/guardian must indicate Temporomandibular joint (TMJ) evaluations in writing “No change,” or must write in any changes to the Comments patient’s health status. The patient or parent/guardian is then Specific guidelines must be followed for proper patient record instructed to sign and date the form to indicate that the information management. is accurate and up to date. Treatment Plan RECALL Once the dentist has reviewed the medical-dental health history form and has dictated any charting or updates needed on the 4. What forms would the business assistant ask a new patient to complete clinical examination form, he or she then records the plan of care before being seen for treatment? on the treatment plan form (Fig. 26.7). The treatment plan for a 5. What type of demographics would be included in the patient registration form? patient is properly sequenced to address all problems that were 6. To verify that the information is accurate, what must a patient provide identified during the examination and diagnosis portions of the after completing a health history form? patient visit. 7. What does the dental history section of the form provide for the dentist? The treatment plan may change course if financial arrangements 8. Give an example of a medical alert. become a factor. For example, a patient’s treatment plan that indicates the need for an implant might change if the patient has limited income and cannot afford the cost of the implant. A second Diagnostic Information–Gathering Forms option of a fixed bridge or a removable partial would then be discussed with the patient to accommodate financial limitations. Physical examination form (posture and gait, vital signs, cogni- tion, and communication skills) Informed Consent Radiographic examination (this can include any of the following exposures: periapical, bitewing, occlusal, panoramic) The informed consent form pertains to a specific treatment or Clinical examination form (extraoral examination, intraoral procedure that has been presented to the patient as part of his or examination, periodontal examination) her treatment needs (Fig. 26.8). This document provides the patient At the completion of a patient’s visit, the diagnostic information– with expected outcomes of treatment and describes possible gathering process will have been completed, and at that time the complications. These individualized forms are more commonly dentist will formulate an assessment of the patient’s oral health used when invasive or extensive treatment is required, such as status from the findings. An assessment is the process of collecting surgical procedures, orthodontics, endodontics, prosthodontics, data and then evaluating or drawing conclusions from the findings. periodontics, and implants. The dentist will do the following: The dentist will review the treatment plan with the patient and Assess a patient’s intraoral and extraoral conditions by completing address any questions or concerns. Once both parties have agreed, a comprehensive clinical examination. the patient, the dentist, and a witness will sign and date the forms. Review all significant findings. Present a diagnosis to the patient. Progress Notes Develop and document a treatment plan with input from the patient. At the end of a procedure, the details of what was completed will Schedule a sequence of appointments to complete treatment be entered in the “Progress notes” section (Fig. 26.9). Specific in a timely manner. information that should be noted on this form includes the Follow through with maintenance appointments in the patient following: care process. Date: This shows the month/day/year of treatment/ communication. Tooth number: If a specific tooth is being treated/discussed, it Clinical Examination should be indicated by the number in this section. This informa- The clinical examination and recall examination form are the most tion allows faster reference to previous appointments. detailed document in the dental record (Fig. 26.6). This form Treatment: This section of the form must be filled out completely provides the dental team with past, present, and future examination and accurately. This should include information about the data, analysis, and charting needs of the patient. This form is patient’s vital signs, scheduled treatment for the day, and the completed for every new patient of the practice and is updated at procedure performed, with the surface related to the procedure. every appointment, including recall appointments with the dental All pertinent information, such as type and amount of anesthesia, hygienist. dental materials used, how the patient tolerated the procedure, The dentist will examine the patient and dictate the findings postoperative instructions, and when to schedule the next visit to the dental assistant to chart or record. Specific areas on the must be recorded. 368 PART 6 Patient Information and Assessment A B Fig. 26.6(A) Example of an electronic clinical examination form. (B) Example of a recall examination form. (Courtesy Henry Schein Practice Solutions, American Fork, UT.)  CHAPTER 26 The Patient’s Dental Record 369 Fig. 26.7 Example of a treatment plan form. (Courtesy Henry Schein Practice Solutions, American Fork, UT.) Communication with patient: This documentation can include GUIDELINES FOR CHARTING ENTRIES IN anything from the patient scheduling/canceling the appointment CLINICAL RECORDS to a follow-up call, communicating with a dental laboratory, or communication with a specialist involved in treatment Keep a separate chart for each patient. Do not use a “group” chart for care. an entire family. Business and financial information is not part of the clinical record. Do It is important to make note that, after each entry, the dentist not include these records in the chart. and clinical staff involved in treatment must sign and date the It is better to chart too much information than too little. entry. Make the chart entry during the examination or patient visit. The longer the time between the procedure and the charting entry, the greater is the chance for error. Write legibly and record the entry accurately in ink. Date and initial the RECALL entry. 9. What term describes the collection of data used to make a correct The chart entry should be sufficiently complete to indicate that nothing diagnosis? was neglected; this includes the reason for the visit, details of the 10. What form in the patient record would provide knowledge to the dental treatment provided, and a record of all instructions to the patient, team of an existing restoration? prescriptions, and referrals. Never change the chart after a problem arises. If a charting error occurs, correct it properly. Entering Data in a Patient’s Dental Record Every entry in a paper or electronic chart should be made as Legal and Ethical Implications if the chart will be seen in a court of law. Specific guidelines must be followed when any type of entry is made in a patient The patient record is the most confidential document that exists record. between the dentist and the patient. The information shared between See Procedure 26.3: Entering Treatment in a Patient Record, the dental healthcare team and the patient is private and must and Procedure 26.4: Correcting a Chart Entry. remain private. 370 PART 6 Patient Information and Assessment Fig. 26.8 Example of the informed consent form. (Courtesy Henry Schein Practice Solutions, American Fork, UT.) Fig. 26.9 Example of a progress notes form. (Courtesy Henry Schein Practice Solutions, American Fork, UT.) Do not discuss patient information, specific treatments, or dentistry, including more integration with healthcare providers, patient discussions with anyone. Information talked about outside will move them forward. the office and then reported could have serious consequences for the dentist, the assistant, and the entire practice. All members Critical Thinking of the dental team should be familiar with HIPAA. 1. What would make a document not legal in a court of law? Eye to the Future 2. You are on the phone with a patient’s insurance company. What form would you refer to from the patient record to make changes The future of dentistry is digital and paperless. Dentists have been to the insurance information? slow to transition in the digital practice by lack of federal incentives 3. How often should the patient update his or her medical-dental and technical assistance. Now, however, changes in the practice of history?  CHAPTER 26 The Patient’s Dental Record 371 4. What form would you use to chart existing restorations and ELECTRONIC RESOURCES present conditions? Additional information related to content in Chapter 26 can be 5. A patient has indicated “yes” on the health history that found on the companion Evolve Web site. he has asthma. Should this be noted as an ALERT? If so, Dentrix Exercise describe how this health condition could affect a dental Practice Quiz appointment. STANDARDS AND CRITERIA FOR DATA ENTERED IN A CLINICAL RECORD All entries must be dated and legible. They are to be completed in black (e.g., patient’s mental health status). For example, instead of “Suspected ink if using a paper chart. drug abuser,” document that “Patient requested narcotic meds after The individual who documents the information must provide a signature routine simple restorative procedure.” or entry of initials. All individuals who have access to the patient record must maintain the In a paper chart, inaccurate entries should never be corrected with confidentiality of the information contained in the document. Information correction fluid or other methods of “blocking out” the original entry. in the record may not be shared with anyone outside of the healthcare Crossing through an entry should be done only to make corrections of team without the patient’s written authorization. errors in documentation and should be marked with a single line A patient’s record must not be altered once it is possible that legal action followed by the initials of the individual who corrected the entry. may be taken by the patient. The patient’s response to treatment (outcomes) should be routinely The patient’s treatment record is the property of the dentist and may not recorded. be removed from the dental practice. Original records and radiographs All appointment cancellations, broken appointments, late arrivals, and may not be given to anyone except through a court order. changes of appointment should be documented, whether patient or Patients have a right to access the information contained within their provider generated. record and are entitled to receive a copy of their record. Release of a All conversations with the patient and with other healthcare providers copy of the record, in part or in its entirety, to anyone requires a written regarding the patient should be documented. request from the patient. Evaluations and statements of “opinion” that the dentist is not The original entry is readable with only a line through it when a charting professionally qualified to make should not be documented in the record error is corrected. DATE TOOTH SERVICE RENDERED 2/10/xx exam, adult prophy 2/15/xx DDA 2/10/xx 3 X-ray, remove amal restoration. Place sedative treatment. If pain persists, refer to endodontist. 2/15/xx DDA PROCEDURE 26.1 Registering a New Patient Consider the following with this procedure: The procedure is to be Full name, birth date, name of spouse or parent documented in the patient record. Home address and telephone numbers (home, cell, work) Employment, name of employer, business address, and telephone Equipment and Supplies number Registration form Name and address of person responsible for payment Black ink pen Method of payment (cash, check, credit, assignment of benefits) Clipboard Dental insurance information (photocopy of both sides of insurance ID card) Procedural Steps PURPOSE This information is necessary for processing financial 1. Explain the need for the form. Hand the registration form on a clipboard arrangements and insurance claims. with a black pen to the patient or instruct patient on using the computer, Name of primary insurance carrier and provide instructions on how to complete and where to return the Referral to the practice document when finished. Emergency contact 2. The business assistant will review the completed form for the necessary Verification that the patient has provided a signature and a date on information: the form 372 PART 6 Patient Information and Assessment PROCEDURE 26.2 Obtaining a Medical-Dental Health History Consider the following with this procedure: The procedure is to be 3. Offer assistance to the patient when completing the form. documented in the patient record. PURPOSE The patient may not understand the terminology or may have a language barrier. Equipment and Supplies 4. Ask the patient to return the form and clipboard to you after he or she Medical-dental health history form has answered all questions. Black ink pen 5. Thank the patient for completing the form and request that the patient Clipboard take a seat in the reception area. 6. Review the form for errors and/or any questions that may arise before Procedural Steps you hand it to the clinical assistant. 1. Explain the need for the information and the importance of the patient 7. Use information from the patient’s medical-dental health history form to completing the form. complete additional documents. Remember, the information provided to 2. Provide the patient with a black ink pen and the form on a clipboard, or you by the patient is confidential and must be maintained as such. access to the electronic version. PROCEDURE 26.3 PROCEDURE 26.4 Entering Treatment in a Patient Record Correcting a Chart Entry Consider the following with this procedure: Enter a thorough explanation of Consider the following with this procedure: The procedure is to be the procedure with correct dental terminology understood by the dental documented in the patient record. team. Goal Equipment and Supplies To gain competency in correcting an error on a patient’s record. Black ink pen Patient’s record or electronic record Procedural Steps 1. Using a black ink pen, draw a single line through the previous entry. Procedural Steps Initial and date the correction. 1. In the Date column, record the date the treatment was provided, using PURPOSE To ensure that the original entry is still readable and that the numbers in a month/date/year format, such as 2/27/20. change is permanent. 2. In the Progress Notes column, record all aspects of the dental 2. Write the corrected entry in ink on the next available line. procedure, such as the tooth, the surfaces of the tooth restored, the 3. Initial and date the new entry. type and amount of anesthetic agent given, the dental materials used, PURPOSE To identify the individual responsible for the chart entry. and information on patient tolerance of the treatment. 3. If appropriate, describe the procedure that was performed with appropriate details, such as whether the tooth was prepared for a crown. PURPOSE The treatment is documented, and this serves as a reference for future appointments. 4. After entering the completed treatment, sign the entry. NOTE Always make sure to have the dentist sign. This verifies that the entry is accurate. 5. Return the completed dental record to the business office. PURPOSE The patient returns to the business office area to make payment for services and to schedule any additional appointments.