Transcript The Patient Record

Chapter 26
The Patient Record
Copyright 2003, Elsevier Science (USA).
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Produced in the United States of America
ISBN 0-7216-9770-4
Copyright 2003, Elsevier Science (USA). All rights reserved.
Introduction
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
 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.
The Function of the Patient Recordcont’d
 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.
Copyright 2003, Elsevier Science (USA). All rights reserved.
The Function of the Patient Recordcont’d
 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.
Copyright 2003, Elsevier Science (USA). All rights reserved.
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.
Copyright 2003, Elsevier Science (USA). All rights reserved.
Components of the Patient Record
 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.
Copyright 2003, Elsevier Science (USA). All rights reserved.
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.
Copyright 2003, Elsevier Science (USA). All rights reserved.
Fig. 26-4 Medical-dental health history form.
Copyright 2003, Elsevier Science (USA). All rights reserved.
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.
Copyright 2003, Elsevier Science (USA). All rights reserved.
Fig. 26-6 Medical-dental health history update form.
Copyright 2003, Elsevier Science (USA). All rights reserved.
Clinical Examination Form
 Provides the dental team with past, present,
and future examination, analysis, and
charting needs of the patient.
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Fig. 26-7 Clinical examination form.
Copyright 2003, Elsevier Science (USA). All rights reserved.
Treatment Plan Form
 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.
Copyright 2003, Elsevier Science (USA). All rights reserved.
Progress Notes Form
 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.
Copyright 2003, Elsevier Science (USA). All rights reserved.
Informed Consent Form
 Provides the patient with what they should
expect as an outcome of treatment, and
describes any possible complications that
might occur.
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Fig. 26-11 Informed consent form.
Copyright 2003, Elsevier Science (USA). All rights reserved.