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21 Cards in this Set
- Front
- Back
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What is the definition of a dental patient record?
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A record of any dental services provided for an inpatient, outpatient, or emergency patient.
Patient's file containing diagnostic and treatment info. |
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What kind of information is contained in a patient's dental record?
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Caries, restorations, medical/dental history, other (personal)
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T or F: the doctor fully owns the patient record.
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False - the patient is the co-owner, if not the majority owner.
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What does a dental record represent? What type of document is it?
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The entire collection of info obtained from, or written about, the patient during the care process.
Medico-legal document that can be used for forensic purposes or civil litigation, so it has to be neat, legible, organized, accurate, up-to-date, CONFIDENTIAL. |
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Who controls where the patient's information goes?
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The patient - they have the right to access the information in the record.
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Is the dentist legally obligated to send copies of the record to whomever the patient desires?
Does the dentist have to comply with any patient request to forward a copy of a dental record? |
Yes, but there may be a fee involved.
Yes. |
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Once a claim is made, do you need the patient's consent to forward the record to your insurance company?
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No.
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Why would a dentist want to forward a record?
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1) 2nd opinion
2) Give background on pt to specialist 3) Give background on pt to physician 4) Insurance billing |
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Is the dentist required to give original records to the patient?
Does a dentist have to make copies of a record available to the patient? |
NO. They may be required by the court, though.
Yes, most state laws require that copies of records are made available to patient, with reproduction cost paid by patient (even if the patient has not paid his fee) |
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Can a dentist alter or delete portions of a patient's record?
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NO. Court will discredit the remainder of the doctor's testimony, find against the doctor.
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What if I make an error in a record?
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SLIDE
Single Line, Initial, Date, Explanation. Don't use white out or scribble. |
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What should you record when a patient calls?
What should you record if the patient is calling with a problem? |
ALL patient calls. Time, date, participants, substance - record it all in charts.
If pt is calling with problem, record all significant statements as verbatim quotes. Instructions, advice, as well as any plans for further contact or follow up. |
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The inclusion of a comprehensive and current medical history serves what purposes?
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1) provides clear picture of pt's condition to other physicians, staff, dentists.
2) if your awareness of particular aspects of a pt's medical history becomes an issue in a legal claim against you, your written record will be important evidence. |
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What should a patient's medical history reflect?
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***aspects of medical history that are pertinent to the dental treatment:
1. allergies 2. significant medical conditions (bleeding disorders) 3. heart disease/conditions **MITRAL VALVE PROLAPSE** 4. current prescription drugs 5. current non-prescription drugs |
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What are primary teeth lettered from?
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A-T
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What is an odontogram?
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Graphic display of teeth in a person's mouth where dental procedures are recorded. Paper or electronic.
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In an odontogram, what is green? What is red? What is blue?
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Green - existing restorations
Red - current problems/conditions (caries, failing restorations, existing pathologies) Blue - completed restorations |
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Facial surface: when it's in the anteriors? Posteriors?
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Anterior - labial
Posterior - buccal |
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Squiggly line on tooth means?
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Missing tooth
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C with white square around it on the tooth means?
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crown with decay underneath where the square is
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In odontogram, yellow color =? silver color =? c with yellow box around it? red color? red R? C with half yellow half gray box?
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composite, amalgam, porcelain or ceramic crown, caries (unspecified), restoration with current caries, porcelain/metal crown
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