Chapter 7 Working with Dental Office Documents Final Study Guide

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Mrs. Hunter

HIPAA: Protects electronic patient health information

Doctors who transmit health information in an electronic transaction are required to use a standard format

The Notice of Privacy form

information that the dental professional is required to give patients regarding the office's privacy practices

HIPAA applies to which records?

Protected PHI is anything that ties a patient's name or Social Security number to that person's health, healthcare, or paymen for health care, such as radiographs, charts or invoices.

Life Cycle of patient records

-Creation
-Distribution
-Use
-Maintenance
-Disposition

Def and Examples: Vital Records

essential documents that cannot be replaced
-Patient clinical and financial charts
-Office's charter and deed, mortgage, or bill of sale

Def and Examples: Important records

Extremely valuable to the operation of the office but are not vital
-accounts payable/recievable
-invoices
-canceled checks
-inventory and payroll
-other federal reglatory records

Def and Examples: Useful Records

definition is difficult to define because one office may consider a document useful, whereas another might find it indispensable. Retained 1-3 yrs
-employment applications
-expired insurance policies
-petty cash vouchers
-bank reconciliations
-general correspondence

Def and Examples: Nonessential Records

documents that lie around, have little importance, and take up space
-notes
-reminders of meetings
-outdated announcements,
-pamphlets

Clinical Records are vital for several reasons

-treatment of patient and serve as a road map to outline future treatment
-malpractice suit [[dental records are admissable as evidence for or against the dentist
-3rd party payment plans to assure treatment has been rendered
- acts as verification of treatment for IRS purposes
-forensic evidence

Clinical records have the following components STUDY

-registration form
-health history and update form
-HIPAA acknowledgement
-Clinical chart or exam form
-progress notes
-dental diagnosis, treatment plan, esimate sheet
-medication history and prescriptions forms
-lab requisitions
-consent forms
-consultation and referral reports
-letters
-postal reciepts
-treatment record
-radiographs
-copies of lab tests

Sorting of Records

color coding is necessary to make sorting, storing and retrieval easier
-yr aging labels can be used to identify inactive patients that may need to be purged from the active storage system
-the 2 digit number indicated the yr of the patients last visit to the office

Patient Registration form

contains general info such as addresses and telephone numbers as well as insurance info

Radiographic films

should be labeled with patients full name, date of exposure, the number and type of films, and the dentists name.
-if copied and transfered, name and date of transfer should be noted

Entering data in a clinical chart

Failure to document any activity completely and accurately may prove costly in a lawsuit

Types of Clinical Data Entries

There are 6 segments: Maxillary and Mandibular Right and Left [[molars and premolars]] and the 2 anterior segments [[ all anterior teeth on R and L arches from Canine to Canine]]

Def and Location: Universal Numbering System

1-32 [[Permanant dentition]] A-T [[Primary]]
Numbering the teeth witht he most posterior tooth on the Max right quadrant 3rd molar. Same for Primary

Def:Mesial

closest to the midline

Def: Distal

opposite of mesial, furthest the midline

Def: Facial

faces the cheek and lips

Def: Labial

same as facial but only on anterior teeth

Def:Buccal

same as facial for posterior teeth

Def: Lingual

surfaces closest the tongue

Def: Occlusal

biting surface of posterior teeth

Def: incisal ridge

edge and is found only on anterior teeth athat have a biting edge

Def: Proximal

where two teeth abut or face each other

Records transfer

-provide accurate and complete dental records
-never change dental records without dating change
-obtained a signed consent before providing copies to anyone other then the patient
-Retain records in accordance with the state statute
-keep originals
-charge a reasonable clerical fee for furnishing records in accordance with local standards
-charge a reasonable professional fee for preparing and furnishing a narrative report for the patient
-require advance payment for clerical and preparation service in accordance with local standards

Rules for entering data on a clinical chart

-Transfer information should be accurate and complete
-general information should be in ink and neat
-underline illnesses in red ink. bright labels can be used
-clinical entries can be made on computer in the treatment room or outside the treatment room
-always check information that has been transferred or entered correctly
-check patient record to make sure treatment has been completed
-verify that the record has been initialed by the dentist and the clinical assistant who performed treatment

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