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  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 patient- registration form. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Introduction  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 Example of the patient record. (From Gaylor LJ: The administrative dental assistant, Philadelphia, 2006, Saunders.) Fig 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  Before dental treatment, the dental team must have the following information:  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  Permanent record  Personal and legal documentation of the patient  Quality assurance  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  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 Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

The Function of the Patient Record  Risk management  The patient record provides documentation of the patient’s condition, diagnoses, and treatment and the patient’s responses to treatment.  Research  The patient record provides a source of data for research purposes. Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Getting to Know Your Patients  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 © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Patient-Registration Form  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 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  Discuss the importance of the patient’s medical-dental health history and its relevance to dental treatment.  Obtain a completed medical-dental health- history 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  Medical-history section  Questions regarding the patient’s medical history, present physical condition, chronic conditions, allergies, and medications currently being taken  Dental-history section  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 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  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  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 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  The patient must update his or her medical- dental health history at every appointment  Health information that may have changed:  Diagnosis of medical conditions  Medications Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Fig 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  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 Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Fig 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  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 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  Treatment is recorded in this section of the patient record.  Always include:  Date  Tooth number  Completed treatment  Signature Copyright © 2009, 2006 by Saunders, an imprint of Elsevier Inc. All rights reserved.

Fig 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  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.  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 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.