1. DOCUMENTATION OF PATIENT’S RECORD
NORZAFIRAH KASSIM
MASYITAH MUSTAFFA

2. DEFINITION
DOCUMENTATION is defined as the material that provides official information or evidence that serves as a record. also can be describe as the process of classifying and annotating texts, photographs, etc.

3. DENTAL RECORD patient’s folders, cards or charts
contain all the information about the patient’s history, investigation done to the patients and also all the treatments that had be done to the patients
records all the important communication between the patients and dental practitioners in the dental clinic

4. BASIC PERSONAL INFORMATION DIAGNOSTIC INFORMATION TREATMENT PLAN NOTES
DENTAL RECORD
BASIC PERSONAL INFORMATION
DIAGNOSTIC INFORMATION
TREATMENT PLAN NOTES
TREATMENT PERFORMED
INFORMED CONSENT
PATIENT RELATED COMMUNICATION
INSTRUCTION FOR HOME CARE

5. IMPORTANCE sign of quality best possible care for the patient
communication between the treating dentist and the patient’s future dentist
Defense of allegations of malpractice
Forensic odontology

6. Organization Of Dental Record (Filing System)
Traditional filing system
Computerized/electronic filing system

7. Government Dental Clinic Cards

9. computerized filling systems (E-clinical)
Confidentiality
Integrity
Accessibility
Adv, disadv

10. Content of Dental Record
database information (name, IC number, birth date, address, occupation and contact information)
Chief Complaint and history of chief complaint
Medical, dental, social histories and habits
Intra-oral and extra-oral examination
Diagnostic and investigation records, including charts, study models and radiographs
conversations about any proposed treatment
potential benefits and risks
alternatives treatment
treatment plan notes
medication prescriptions
Types, dose, amount
directions for use and number of refills
Treatment done to the patient

11. laboratory work order forms
mold and shade of teeth used in bridgework and dentures and shade of synthetics and plastics
referral letters and consultations with referring or referral dentists and/or physicians
patient noncompliance and missed appointment notes
follow-up and periodic visit records
postoperative or home instructions (or reference to pamphlets given)
consent forms
waivers and authorizations
conversations with patients dated and initialed (both in-office and on telephone, even calls received outside the office)
correspondence, including dismissal letter; if appropriate

12. How to write in a record
Document the record while patient still in the clinic or as soon as patient leaves
All entries should be dated, initialed and handwritten in ink and/or computer printed
Easy to be read
Any attachment be include in the record eg; radiograph, informed consent etc
If patient refuse to accept the recommended treatment plan, notate the reason

13. Use only common abbreviation.
Simply cross out any correction that need to be done and not obliterate an entry. Every correction must have initial and date.
No blank lines between entries.

14. Consequences of error in dental record
Prevent professional liability insurance companies to successfully defending dentists against unfounded allegations of malpractice
Allegation – a claim of fact by a party in a pleading which the party claim to be able to prove. (dakwaan)

15. Conclusion
Documentation of dental record is vey important. It benefit both patients and dentists. Dental record is a legal document that cannot be neglected.