DOCUMENTATION OF PATIENT’S RECORD

DOCUMENTATION OF PATIENT’S RECORD

NORZAFIRAH KASSIMMASYITAH MUSTAFFA

DEFINITION

DOCUMENTATIONis 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.

DENTAL RECORDpatient’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

DENTAL RECORD

BASIC PERSONAL INFORMATION

DIAGNOSTIC INFORMATION

TREATMENT PLAN NOTES

TREATMENT PERFORMED

INFORMED CONSENT

PATIENT RELATED COMMUNICATION

INSTRUCTION FOR HOME

CARE

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

Organization Of Dental Record(Filing System)

1. Traditional filing system2. Computerized/electronic filing system

Government Dental Clinic Cards

computerized filling systems(E-clinical)

• Confidentiality• Integrity• Accessibility

• Adv, disadv

Content of Dental Record1. database information (name, IC number, birth date, address, occupation

and contact information)2. Chief Complaint and history of chief complaint3. Medical, dental, social histories and habits4. Intra-oral and extra-oral examination5. Diagnostic and investigation records, including charts, study models and

radiographs6. conversations about any proposed treatment

potential benefits and risks alternatives treatment

7. treatment plan notes8. medication prescriptions

Types, dose, amount directions for use and number of refills

9. Treatment done to the patient

1. laboratory work order forms2. mold and shade of teeth used in bridgework and dentures and shade of

synthetics and plastics3. referral letters and consultations with referring or referral dentists and/or

physicians4. patient noncompliance and missed appointment notes5. follow-up and periodic visit records6. postoperative or home instructions (or reference to pamphlets given)7. consent forms8. waivers and authorizations9. conversations with patients dated and initialed (both in-office and on

telephone, even calls received outside the office)10. correspondence, including dismissal letter; if appropriate

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

• 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.

Consequences of error in dental record

Prevent professional liability insurance companies to successfully defending dentists against unfounded allegations of malpractice

Conclusion

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