Chapter 26. Lesson /8/2010. Chapter 26. The Patient Record. Introduction. Learning Objectives. Critical Information

Transcription

1 The Patient Record Lesson 26.1 Learning Objectives Introduction 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 patientregistration form. The patient record is the principal document containing critical information you will need to manage each patient in the dental practice. Fig Example of the patient record. Critical Information Before dental treatment, the dental team must have the following information: Patient registration Medical-dental health history Medical-alert information 1

2 The Patient Record Examples of Quality Assurance 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. 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 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. 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. Patient-Registration Form Fig Example of a 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 2

3 Learning Objectives Lesson 26.2 Discuss the importance of the patient s medical-dental health history and its relevance to dental treatment. Obtain a completed medical-dental healthhistory form for a new patient. Prepare and organize a patient record. Medical-Dental Health History Form Fig Example of a 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 Medical-Alert Information Fig Examples of medical-alert stickers. (Courtesy of SYCOM, Madison, Wis) 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. 3

4 Health-History Update Fig Example of the medical-dental health-history-update form. (From Gaylor LJ: The administrative dental assistant, ed 2,St Louis, 2006, Saunders.) The patient must update his or her medicaldental health history at every appointment Health information that may have changed: Diagnosis of medical conditions Medications Clinical-Examination Form Fig 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 Treatment-Plan Form Fig Example of a treatment-plan form. This form is sequenced to address all problems identified during the examination and diagnosis portion of the patient visit. 4

5 Progress-Notes Form Treatment is recorded in this section of the patient record. Always include: Date Tooth number Completed treatment Signature Fig Example of a progress-notes form. 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. Fig Example of the informed-consent form. 5