Copyright 2003, Elsevier Science (USA). All rights reserved. Chapter 26 The Patient Record Copyright 2003, Elsevier Science (USA). All rights reserved.

Copyright 2003, Elsevier Science (USA). All rights reserved.

Chapter 26The Patient Record

Chapter 26The Patient Record

Copyright 2003, Elsevier Science (USA).

All rights reserved. No part of this product may be reproduced or transmitted in any form or by any means, electronic or mechanical, including input into or storage in any information system, without permission in writing from the publisher.

PowerPoint® presentation slides may be displayed and may be reproduced in print form for instructional purposes only, provided a proper copyright notice appears on the last page of each print-out.

Produced in the United States of America

ISBN 0-7216-9770-4


IntroductionIntroduction The patient record is the principal

document of information that you will manage for each patient in your dental practice.

The patient record is the principal document of information that you will manage for each patient in your dental practice.


The Function of the Patient Record The Function of the Patient Record Permanent record is a personal and

legal document of the dentist. Quality assurance: Primary source of

information to determine the overall quality of care the patient has received.

Permanent record is a personal and legal document of the dentist.

Quality assurance: Primary source of information to determine the overall quality of care the patient has received.


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 are

taken. • Current and up-to-date emergency standards

maintained by the dental team. • Current and up-to-date licenses, registrations,

and training.

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 are

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 cont’d The Function of the Patient Record cont’d


Risk management• Documentation regarding the

patient’s condition, diagnoses, treatment, and the patients responses to treatment.

Research • The patient record provides a source

of data for research purposes.

Risk management• Documentation regarding the

patient’s condition, diagnoses, treatment, and the patients responses to treatment.

Research • The patient record provides a source

of data for research purposes.

The Function of the Patient Record cont’d The Function of the Patient Record cont’d


Getting To Know Your Patient Getting To Know Your Patient

Information Gathering• Address the patient, using his or her

surname.• Give the reason for obtaining the

information.• Answer any questions the patient

may have.

Information Gathering• Address the patient, using his or her

surname.• Give the reason for obtaining the

information.• Answer any questions the patient

may have.


Components of the Patient Record Components of the Patient Record

Patient registration form• Patient information• Insurance information• Responsible party • Signature and date

Patient registration form• Patient information• Insurance information• Responsible party • Signature and date


Fig. 26-3 Patient registration form. Fig. 26-3 Patient registration form.


Medical-Dental Health History Form Medical-Dental Health History Form Medical history section

• Questions regarding the patient’s past medical history, present physical condition, chronic conditions, allergies, and medications that are currently being taken.

Dental history section• Gains information about the patient’s

previous dental treatment and care, and their feelings toward dentistry and how important dental care is to them.

Medical history section • Questions regarding the patient’s past

medical history, present physical condition, chronic conditions, allergies, and medications that are currently being taken.

Dental history section• Gains information about the patient’s

previous dental treatment and care, and their feelings toward dentistry and how important dental care is to them.


Fig. 26-4 Medical-dental health history form. Fig. 26-4 Medical-dental health history form.


Medical Alert Information Medical Alert Information

Note to the dental health team of medical alerts or other precautions that need to be followed in providing safe care to that patient.

Note to the dental health team of medical alerts or other precautions that need to be followed in providing safe care to that patient.


Fig. 26-6 Medical-dental health history update form. Fig. 26-6 Medical-dental health history update form.


Clinical Examination Form Clinical Examination Form

Provides the dental team with past, present, and future examination, analysis, and charting needs of the patient.

Provides the dental team with past, present, and future examination, analysis, and charting needs of the patient.


Fig. 26-7 Clinical examination form. Fig. 26-7 Clinical examination form.


Treatment Plan Form Treatment Plan Form

Sequenced to address all problems identified during the examination and diagnosis portion of the patient visit.

Sequenced to address all problems identified during the examination and diagnosis portion of the patient visit.


Fig. 26-9 Treatment plan form. Fig. 26-9 Treatment plan form.


Progress Notes Form Progress Notes Form

Section of the patient record where treatment is recorded.

Always include:• Date• Tooth number• Completed treatment• Signature

Section of the patient record where treatment is recorded.

Always include:• Date• Tooth number• Completed treatment• Signature


Fig. 26-10 Progress notes form.Fig. 26-10 Progress notes form.


Informed Consent Form Informed Consent Form

Provides the patient with what they should expect as an outcome of treatment, and describes any possible complications that might occur.

Provides the patient with what they should expect as an outcome of treatment, and describes any possible complications that might occur.


Fig. 26-11 Informed consent form. Fig. 26-11 Informed consent form.

Copyright 2003, Elsevier Science (USA). All rights reserved. Chapter 26 The Patient Record Copyright 2003, Elsevier Science (USA). All rights reserved.

Documents

patient record copyright

active patient

patient record contd

elsevier science usa

primary source of information

information system

patients condition

patients responses