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26 Cards in this Set
- Front
- Back
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Assessment |
Process of collecting data and then evaluating or drawing conclusions for the findings |
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Chronic |
Persisting over a long period of time |
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Chronological |
Arranged according to the time occurrence. Earliest to most recent |
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Alert |
To bring attention to a specific mediation or clinical condition |
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Demographic |
Person info that can include addresses, phone, work info, and also statistical characteristics of populations |
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Diagnosis |
Identification or determination of the nature and cause of a disease or injury through evaluation of a patients history and examination findings |
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Forensic |
Preparing to the indents of an basis of scientific methods |
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HIPAA |
Health insurance portability and accountability act of 1969 describes the federal regulations the ensure privacy regarding a patients health info |
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Litigation |
Act of initiating legal proceedings as in a law suit |
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Quality assurance |
Program in place for monitoring and evaluating a project, service, or facility to ensure that standards of quality are being met |
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Registration |
Act of completing forms my providing personal info |
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Dental record |
Consist of several components which can includes patients medial/dental history, examinations, diagnosis, radiographs, referral letters, prescriptions, treatment, prognosis of dental health. |
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Patient compliance |
Dental record contains confidential info related to patients background. It is important for the team to follow standard when documenting and handling info Besides being used for clinical purposes it can also be used for legal. |
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Permanent record |
Dental record is permanent document of the dentist and also considered a legal documents. Legal reasons Evidence in a legal settlement or lawsuit Forensic purposes Reference for appropriate third parties such as dental insurance companies |
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Quality insurance |
Dentist will use patient record as primary source of info in determining overall quality of care. Examples; Routine forms are competed for each patient and verified with signature and date Timely recall Completed dental record is kept for each active patient Documentation includes info when radiographs are taken Current emergencies protocols Up to date licenses, registration, certifications and training for dental team members are maintained |
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Risk management |
For the dentist to avoid litigation such as malpractice suit in the process or outcome of treating patients, a record must me kept and completed. |
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Research |
A compete and chronological order of dental record or of dental condition that have been diagnosed could provide data to be used for research purposes or education |
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Election dental record |
Benefits of going paperless: Access to dental record is safeguarded in many locations of office To preform practice management tasks such as reg, scheduling, billing, and inquiry about an insurance status Allow dental team to enter relevant clinical documents, charting, lab prescription and electronically prescribe medication To share health info with authorized providers across then more then one healthcare organization |
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Patient record forms |
(Info gathering forms) is competed by a patient before treatment is provided. Forms include: Patient reg - person info Medical/dental info Medical alert info Consent forms |
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Medical - dental health history update |
Returning patients are to be asked to update medical/dental history at EVERY appointment even if you just saw this patient. A slight change in medication condition could cause a reaction with anesthesia or pain control methods used by the dentist |
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Diagnostic info gathering forms |
Physical exam - posture,gait, vital signs, cognition, commutation Radio graphics - Clinical exam - extraoral and intraoral exam and periodontal exam After completion the dentist with access patients intraoral/extraoral conditions by completing a comprehensive clinical exam Review all findings Present diagnosis to patient Develop and document a treatment plan with input from the patient Schedule a sequence of appointment to compete treatment in a timely manner Follow through with maintenance appointments |
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Clinical exam |
Clinical exam and recall exam form is most detail document in patient dental record. This provides dental treatment with past, present, and future exam data, analysis, and charting needs of the patient. Competed for every new patient and then updated every appointment. Includes: Patients name and exam date Charting system for existing restorations and present conditions Charting system for periodontal conditions Patients chief complaint Occlusal evaluations TMJ Comments |
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Treatment plan |
One the dentist has reviewed the medical and dental health history form and has dictated any charting or updates needed on clinical exam for. He/she records the plan of care on the treatment plan form. Treatment plan is patient properly sequenced to address all problems that were identifying during exam. Treatment plan may vary due to financial reasons |
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Informed consent |
Both the dentist right a form agreeing to treatment plan |
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Progress notes |
At the conclusion of a procedure the details of what was accomplished will be entered in the progress notes section and should include: Date Tooth number Treatment Commutation with patient |
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Entering data in a patients dental record |
Every entry on paper or electronic can be used in the court of law. Specific guidelines must be followed when any times of entry is done |
