ADA lecture Flashcards
What are the requirements for professional behaviour according to the dental board of australia?
Dentists must display standard of behaviour that warrants the trust and respect of the community.
Observing & practising principles of ethical conduct
Includes maintaining health records (Section 8.4)
What are the features of adequate health records?
Maintaining clear & accurate health records essential for good patient care
A) keeping accurate, up-to-date, factual, objective & legible records that report relevant details of clinical Hx, clinical findings, investigations, info given to patients/clients, medication & other management
B) ensure records held securely, not subject to unauthorised access
C) ensure records show respect for patients & don’t have demeaning/derogatory remarks
D) ensure records are sufficient to facilitate continuity of care
E) make records at time of events or asap after
F) recognise right of patients to access information and facilitating that access
G) facilitate transfer of health information when requested by patients
What are the features of poor dental records?
Breach of appropriate standard of care
Can expose patient/dentist to risk (eg potential litigation)
Inefficient
What causes bad health recording habits to take place?
Laziness, wanting to cut corners
Mimic older dentists by conforming to the “usual” practice standards
Time pressure/lack of opportunity
Who should be able to understand health records?
Pt/guardian/legal rep
Private health insurance (audits): Can request restitution if deemed unacceptible.
Department of human services
AHPRA/DBA
Professional indemnifier (eg if a patient complaint, defending claim of negligence)
Other complaint resolution process
General insurance companies.
Courts
Coroner/Forensic investigators
What information should be recorded for the dental board of Australia?
Pt details: ID and completed + current Med Hx.
Clinical details for each appointment: Date of visit, identifying details of practitioner giving tx, info about type of exam conducted, relevant hx, clinical findings + observations, Dx, TP and alternatives, Consent of patients, all procedures conducted, instrument batch tracking, medicines/drugs prescribed (Quantity, name, dose, instructions), details of advice given.
Usual sequelae of treatment
Radiographs
All other digital info
