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Documentation: Instrumentation Week 13
Terms in this set (33)
A document that contains information identifying an individual patient as well as all information related to the patient's care. Official part of the permanent record.
What two forms can the patient record come in?
Handwritten and electronic
What does the patient record provide?
legal evidence, provides communication, includes copies of correspondence with dental specialists or medical practitioners, and coordinated planning and continuity of care is facilitated.
Documentation should be :
thorough and comprehensive; entries recorded legibly in ink; neatness in the markings of symbols, drawings and labels goes hand in hand with the accuracy the examination; use only standard abbreviations and symbols. . . when in doubt spell it out correctly
The need for careful, thorough examination cannot be __________________.
__________________ and ___________________ are necessary in order that each slight deviation from normal may be entered on the record
concentration and attention
recorded promptly; clear concise subjective statements; dated and signed
If it isn't written down/posted. . .
it didn't happen
patient's right to keep health information private and control who can access it
protocols that protect patient information to avoid inappropriate disclosure
policies to keep information private
authorized personnel only
can occur against even a RDH who rountinely meets every standed when providing dental hygiene care
What should be obtained before initiating treatment?
informed consent; document informed consent
What is the best protection for the clinican against allegations of wrongdoing?
excellent comprehensive documentaion
Dental charts can be used for:
protection; identification-forensic dentistry; a systematic procedure (Sequence); a record of deviations from normal that may be signs and symptoms of disease
A systematic procedure (sequence)
one kind of item for entire mouth; increases accurancy because only one train of thought ; example- record pockets, record recession
Types of charting
dental chart, perio chart, separate preferred; charts should be neat and accurate; there are also anatomic and geometric charts
chronological history of treatment received by the patient during each appointment; includes all aspects of the the dental hygiene process of care (ADPIED); records all interactions between the patient and the practice; consults with dentist or other health providers
Essentials of good notes
each entry is dated and signed by the clinician; treatment rendered; does not include personal opinion, speculation; derogatory statements, or information about financial matters. Systematic; standardized; detailed; SOAP
Good notes should follow SOAP:
subjective, objective, assessment; procedure
characteristics perceived by the patient or clinican; age, gender, type of appt, medical history findings, patient's chief complaint, self-care regimen, social history
characteristic observed during examination; head and neck exam findings, perio exam findings; bleeding; soft tissue condition; hard tissue exam findings; current cavitated carious lesions demineralized noncavitiated lesions; radiographic findings; comparison of current findings with previous findings
identification of problems or patients needs; risk factors for oral disease; caries risk level; calculus level; current perio diagnosis; perio disease risk level
interventions performed or planned; DH interventions performed; local anes applied; consults with dentist or other health professionals; self-care instructions; coals for patient improvement; pending/planned DH interventions
How to correct errors?
Use one line to cross out the error and initial and date the error; do no erase, white out, or "scratch out";
Late entries follow ____________________________ and noted as a late entry including date and time
most recent entry
ADPIED: Assessment; all findings (Medical/dental history; Oral Exam; Perio Charting; Radiographic survey; dental charting; CSI; PCR)
ADPIED: Class (based on CSI) and Type (perio case type)
ADPIED: Treatment plan/Care Planning; coding is used (Prophylaxis 1110, Perio maintenanc 4910; scaling and root planning 4341 or 4342)
OHI; Prophylaxis or SC/RP; Polish; Fluoride
Reassessment (Recall and Referral)
done throughout the process of care
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