Transcript Chapter 7 Body Systems

The Patient Record
Chapter 26
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Chapter 26
Lesson 26.1
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Learning Objectives
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Pronounce, define, and spell the Key Terms.
Identify the purpose of a patient record.
Describe each form in the patient record.
Supervise the completion of a new patientregistration form.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Introduction
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The patient record is the principal document
containing critical information you will need to
manage each patient in the dental practice.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Fig. 26-1 Example of the patient record.
(From Gaylor LJ: The administrative dental assistant, Philadelphia, 2006, Saunders.)
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Critical Information
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Before dental treatment, the dental team must
have the following information:
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Patient registration
Medical-dental health history
Medical-alert information
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.
The Patient Record
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Permanent record
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Personal and legal documentation of the patient
Quality assurance
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Primary source of information used by the dental
team to determine the overall quality of care the
patient has received.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Examples of Quality Assurance
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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 were
taken
Current and up-to-date emergency standards
maintained by the dental team
Current and up-to-date licenses, registrations,
and training
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The Function of the Patient Record
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Risk management
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The patient record provides documentation of the
patient’s condition, diagnoses, and treatment and
the patient’s responses to treatment.
Research
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The patient record provides a source of data for
research purposes.
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Getting to Know Your Patients
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Information-gathering
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Address the patient, using his or her surname.
Give the reason for obtaining the information.
Answer any questions the patient may have.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Patient-Registration Form
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Patient information: full name, date of birth,
residence, phone number, employment,
spouse’s information
Insurance information: employee’s name and
date of birth; employer’s name, address, and
phone number; name of insurance carrier and
policy number
Responsible party: person responsible for
payment of the account
Signature and date: verifies the accuracy
of information
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Fig. 26-4 Example of a patient-registration form.
(From Gaylor LJ: The administrative dental assistant, Philadelphia, 2006, Saunders.)
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Chapter 26
Lesson 26.2
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Learning Objectives
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Discuss the importance of the patient’s
medical-dental health history and its
relevance to dental treatment.
Obtain a completed medical-dental healthhistory form for a new patient.
Prepare and organize a patient record.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Medical-Dental Health History Form
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Medical-history section
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Questions regarding the patient’s medical history,
present physical condition, chronic conditions,
allergies, and medications currently being taken
Dental-history section
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Information about the patient’s previous dental
treatment and care and how the patient feels
about dentistry and how important dental care is to
him or her
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Fig. 26-5 Example of a medical-dental health-history form.
(From Gaylor LJ: The administrative dental assistant, Philadelphia, 2006, Saunders.)
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Medical-Alert Information
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Note to the dental healthcare team of medical
conditions, allergic reactions, and
medications that could interfere with dental
treatment or be life-threatening to the patient
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Place an alert sticker on the inside of the patient’s
record.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Fig. 26-6 Examples of medical-alert stickers.
(Courtesy of SYCOM, Madison, Wis)
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Health-History Update
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The patient must update his or her medicaldental health history at every appointment
Health information that may have changed:
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Diagnosis of medical conditions
Medications
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Fig. 26-7 Example of the medical-dental health-history-update form.
(From Gaylor LJ: The administrative dental assistant, ed 2,St Louis, 2006, Saunders.)
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Clinical-Examination Form
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Provides the dental team with past, present,
and future examination, analysis, and
charting needs of the patient:
Patient’s name and date of examination
 Charting of existing restorations and present
conditions
 Charting of periodontal conditions
 Patient’s chief complaint
 Findings of occlusal evaluations
 Findings of temporomandibular joint evaluations
 Comments
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Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Fig. 26-8 Clinical-examination form.
(From Gaylor LJ: The administrative dental assistant, Philadelphia, 2006, Saunders.)
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Treatment-Plan Form
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This form is sequenced to address all
problems identified during the examination
and diagnosis portion of the patient visit.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Fig. 26-9 Example of a treatment-plan form.
(From Gaylor LJ: The administrative dental assistant, Philadelphia, 2006, Saunders.)
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Progress-Notes Form
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Treatment is recorded in this section of the
patient record.
Always include:
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Date
Tooth number
Completed treatment
Signature
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Fig. 26-10 Example of a progress-notes form.
(From Gaylor LJ: The administrative dental assistant, Philadelphia, 2006, Saunders.)
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Informed-Consent Form
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This form, related to a specific treatment or
procedure, provides the patient with the
expected outcomes of treatment and
describes any possible complications that
might occur.
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Commonly used for invasive or extensive
treatment, such as in specialty procedures.
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.
Fig. 26-11 Example of the informed-consent form.
(From Gaylor LJ: The administrative dental assistant, Philadelphia, 2006, Saunders.)
Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.