Documentation

Question 1

You should have complete and accurate documentation of:

Answer 1

-Patient assessment
-diagnosis
-care plan
-consent
-treatment implementation

Question 2

Purpose of documentation:

Answer 2

-Means of communication between the members of the health team, as well as with their patients
-Facilitates coordinated planning and continuity of care
-Serve as a basis for evaluation of the quality of care (or standard of care)
-Data from health records are utilized in research and education
-Defense in malpractice claims
-Evidence for forensic situation (Disaster victim identification)

Question 3

Good documentation in a pt record is:

Answer 3

-Able to be read and understood by a third party
-Avoid abbreviations unless a list is maintained by the practice
-Accurate and comprehensive
-Legible
-Objective

Question 4

Proper pt record entries are:

Answer 4

-recorded promptly during or following treatment
-Recorded using clear and concise statements
-Dated
-Signed by the clinician

Question 5

Components of a Patient Record:

Answer 5

-All information collected during initial examination and during continued care appointments is an official part of the permanent records
-All components of the dental hygiene process of care are addressed
-Required components:
- Signed acknowledgment of confidentiality measures
- Medical history and vital signs
- Dental history
- Clinical assessment and diagnosis
- Radiographic assessment
- Treatment recommendations and written treatment plan
- Informed consent
- Services rendered note for each patient visit

Question 6

Components of a Patient Record (additional)

Answer 6

Additional components, required when applicable, include:
- Radiographs
- Caries risk assessment
- Anesthesia records
- Study models
- Oral photographs
- Orthodontic records, if available
- Laboratory orders and test results
- Referral records and copies of consultation correspondence with dental specialists or medical practitioners

Question 7

Handwritten Record
s

Answer 7

• Handwritten records are recorded legibly and written in ink
• Mistakes are corrected by placing a single line through the error, writing the correct information immediately after, and signing the entry
• If a late entry is necessary, the new information:
  
  • Follows the most recent entry in the patient record
  • Is noted as a late entry with a cross-reference to the original chart entry
  • Includes the date and time that the late entry was made
• Strict infection control protocols are required to prevent contamination of paper records during patient care (can’t sterilize paper)
• For written records, a filing system is needed that provides accessibility to the health records by authorized personnel only.

Question 8

Benefits of Electronic Health Record (EHR)


Answer 8

-Legible record of patient care accessible in real time
-Standardized format that is customizable
-Information sharing between providers to eliminate duplication of care
-Allow public health entities to gather data
-Enhance communication with consulting dental specialists, medical providers, or other multidisciplinary team members who may not be together at one clinical site
-Maintain digital radiographs and photographs within the patient record

Question 9

Challenges of EHR

Answer 9

-Computer skills required.
-Technical support needed when problems arise so patient care is not interrupted.
-Computerized records require computer terminals where only authorized personnel can access required information.
-Computer monitors are directed away from the view of unauthorized persons.
-Infection control protocols include providing plastic barriers for computer keyboard and mouse.

Question 10

Charting Purpose

Answer 10

-Dental chart (hard tissue): diagrammatic representation of existing conditions of the teeth
-Examples: Restorations, Caries
-Periodontal chart: indicates clinical features of the periodontium
Dental and periodontal charts are updated routinely to record changes in the patient’s oral features
-Symbols, drawings, and labels used need to be accurate representations of the oral condition
- In EHR, charting symbols are standardized

Question 11

the purpose of each type of charting is defined by its

Answer 11

title

Question 12

Charting purpose within the process of care

Answer 12

-Care planning: The charting is a graphic representation of the existing condition of the patient’s teeth and periodontium from which needed treatment procedures can be organized into a treatment plan
-Treatment: During dental and dental hygiene appointments, the charting is useful for guiding specific procedures
-Evaluation: The outcome and degree of treatment effects are determined by comparing the findings of the initially recorded examination with periodic follow-up examinations
-Protection: In the event of misunderstanding by a patient, or if legal questions should arise, the records and chartings are evidence
-Identification: In the event of emergency, accident, or disaster, a patient may be identified by the teeth for which a record has been maintained.

Question 13

T/F- there are many variations of chart forms

Answer 13

true

Question 14

Sequence of charting-

Answer 14

-Basic entries
-Systematic Procedure
-Radiographic Charting
-supplemental observations
-Study Models

Question 15

Sequence of charting- Basic entries

Answer 15

-Name, birth date, address, phone number, emergency contact
-Date of appointment: Every entry is dated

Question 16

Sequence of charting- systematic procedure

Answer 16

-A set routine is essential for complete and accurate charting
-Charting all of one item for the entire mouth, rather than complete chartings of one tooth, helps to ensure accuracy

Question 17

Sequence of charting- radiographic charting

Answer 17

-Without presence of the patient (in private practice, not at ODU):
-Missing, unerupted, impacted teeth
-Endodontic treatment
-Overhanging margins of existing restorations
-Suspected caries
-Radiographic bone loss
-Other deviation from normal evident from the radiographs.

Question 18

Documenting Extraoral and
 Intraoral Examination

Answer 18

-Specific objective: recognition of any deviations from normal that may be signs and symptoms of disease
-Occlusion
-Include amount and distribution of deposits (Calculus, Stain and Biofilm or other soft deposits)

Question 19

Dental charting records

Answer 19

-Visual representation of observed condition of the teeth i
-Include:
- missing, impacted, or supernumerary teeth
-existing restorations
-prostheses
-sealants
-suspected caries
-open contacts
-Include: factors related to occlusion (i.e. attrition and wear facets)
-Update as changes occur

Question 20

Tooth numbering systems-

Answer 20

-Universal
-International
-Palmer notation system

Question 21

Universal Numbering system

Answer 21

AKA ADA system
Permanent- 1-32
primary- A-T

Question 22

International numbering system is aka

Answer 22

the two digit system

Question 23

International (two digit)

Answer 23

-Quadrant numbers
1 = Maxillary right
2 = Maxillary left
3 = Mandibular left
4 = Mandibular right
-Tooth numbers within each quadrant:
-Start with number 1 at the midline (central incisor) to number 8, third molar.

ex- tooth #8 is 11 pronounced “one, one”

Primary teeth-Quadrant numbers
5 = Maxillary right
6 = Maxillary left
7 = Mandibular left
8 = Mandibular right
Tooth numbers within each quadrant: Number 1 is the central incisor, and number 5 is the second primary molar.

Ex tooth #E is 51 pronounced 5, 1

Question 24

palmer system

Question 25

Periodontal Records

Answer 25

-Description of findings related to patient’s periodontal status: -Describing the gingiva -Charting of probe depths, gingival margin, furcations, mobility, bleeding, mucogingival involvement, food impaction -Charting inadequate attached gingiva

Question 26

Care Plan Records

Answer 26

-Dental Hygiene Care Plan includes dental hygiene diagnostic statements -Addresses the patient’s risk factors -Included in the patient’s record

Question 27

Informed Consent should not be confused with

Answer 27

Initial consent

Question 28

Informed Consent

Answer 28

Documentation of informed consent must be obtained before initiating treatment -pt is consenting to recommended treatment

Question 29

Progress Note 
(Ex. services rendered)

Answer 29

-purpose of visit -history review -assessment findings FINISHLATER

Question 30

In clinic, services rendered note must be completed when?

Answer 30

before you leave the clinic

Question 31

Documentation of Patient Visit

Answer 31

-Documentation completed during or immediately following a patient visit (progress note) = chronologic history of treatment received by the patient during each appointment -Essentials of Good Progress Notes -Document all aspects of dental hygiene process of care and records all interactions between the patient and the practice -Each entry in the patient record is dated and signed by the clinician. -The use of unique abbreviations that are not easily understood by others can cause clinical or legal problems -(See Volume I for approved abbreviations)

Question 32

What does services rendered look like in axiUm?

Answer 32

a notepad with a plus sign

Question 33

SOAP Approach

Answer 33

-A systematic, standardized approach to writing patient progress notes assures that no details are missing from patient’s record -S = Subjective (what pt is telling you, unverified information) -O = Objective (clinican observation) -A = Assessment (or analysis) (diagnosis) -P = Procedures (provided or planned treatment)

Question 34

S in SOAP

Question 35

O in SOAP

Question 36

A in SOAP

Question 37

P in SOAP

Question 38

HIPPA stands for

Answer 38

Health Insurance Portability and Accountability Act

Question 39

Health Insurance Portability and Accountability Act

Answer 39

-Health Insurance Portability and Accountability Act of 1996 -Took effect for dental practices in the United States on April 14, 2003 Protect patient records and other health-related information -Law applies to: -healthcare facilities -healthcare insurance companies -healthcare providers -Some states may have stricter laws that take precedence over the federal standards

Question 40

HIPAA is divided into 2 components that address:

Answer 40

-The current law is divided into two separate components that address: -Privacy and the patient’s ability to access their health information -Security of patient information in healthcare settings

Question 41

The HIPAA Privacy Rule:

Answer 41

Establishes a national standard to protect individual’s privacy and access to medical records and other health information

Question 42

HIPPA-Healthcare facilities are responsible to:

Answer 42

- Develop required privacy and confidentiality forms - Adopt written privacy policies and educate staff about confidentiality of patient information - Appoint staff privacy officers and privacy contact persons - Provide patients with a Notice of Privacy Practices document at the beginning of their care and receive signed acknowledgment of receipt - Implement security measures, policies, and formal protocols that protect patient information - Conduct analysis of security risks and vulnerabilities. - Establish sanctions for workforce members who fail to comply with policies

Question 43

HIPAA- Healthcare providers are responsible to:

Answer 43

Comply with protocols and practices that protect patient information and avoid inappropriate disclosure

Question 44

HIPAA- Patient Rights

Answer 44

Patients have the right to: - Receive a copy of personal health records - Ask to change incorrect or incomplete information - Receive reports on when, why, and with whom their health information is shared - Decide, in some cases (such as marketing), whether health information can be shared - Ask to be contacted regarding health information in a specific location or by a specific method such as telephone, e-mail, or mail - File a complaint with the provider, health insurer, or United States government regarding concerns about use of their health information

Question 45

HIPAA Security Rule

Answer 45

- Updated in 2013 to enhance digital security standards and enforcement - Establishes a national set of security standards for protecting health information that is held or transferred in electronic form - Comprises three separate standards: - Administrative safeguards: limitation of access to appropriate members in the workforce - Physical safeguards: use of storage systems and procedures that prevent access for unauthorized individuals -Technical safeguards: use of technology, such as coding and encryption, to control access to patient information.

Question 46

HIPAA Security rule has how many safeguards?

Answer 46

three

Question 47

What are the three safeguards under the HIPAA Security Rule?

Answer 47

- Administrative safeguards: limitation of access to appropriate members in the workforce - Physical safeguards: use of storage systems and procedures that prevent access for unauthorized individuals - Technical safeguards: use of technology, such as coding and encryption, to control access to patient information.