LECTURE 5 & 6 Flashcards
(44 cards)
also known as information management
RECORDS MANAGEMENT
logical, functional system for storing and retrieving information
RECORDS MANAGEMENT
LIFE CYCLE OF A RECORD
→creation
→distribution
→use
→maintenance
→disposition
started on paper or the data
entered into the computer
Permanent Record
may not be stored with the
active clinical charts
Transient Record
→protects the patient and the dentist
→provides information for tax purposes
FINANCIAL RECORDS
if inadequate or incomplete, results in poor public relations and can create unnecessary legal problems with the state and
federal governments, and third-party payers
FINANCIAL RECORDS
on ledger can be used for a family unit or for a responsible
party; whereas with clinical records, it is created for each
individual
FINANCIAL RECORDS
collection of all information about the patient’s dental treatment
CLINICAL RECORDS
accurate clinical records are vital for several reasons:
o serve as a road map; contain the patient’s history and
outline future treatment
CLINICAL RECORDS
o legally admissible as evidence; can be used for, or against
the dentist
o third party payment plans use to review if services have
been rendered adequately
CLINICAL RECORDS
o verification of treatment rendered for Internal Revenue
Services purposes
o vital in forensic odontology
CLINICAL RECORDS
8 ½ x 11 inch file envelope or folder (5 x 8 inches)
PATIENT FILE ENVELOPE OR FOLDER
folders may have preprinted formats with spaces for patient
information including patient’s name, address, and phone
number
PATIENT FILE ENVELOPE OR FOLDER
→ may be plain or color coded; end tab file folder
→ alpha or numeric label system; year aging labels
PATIENT FILE ENVELOPE OR FOLDER
→ contains general information such as addresses and phone
numbers, as well as employment and insurance information
→ incomplete information on this form can complicate account
collection later
PATIENT REGISTRATION FORM
→combined with patient registration form
→signed and dated by the patient
→with children, signed by the parent/guardian, not by the
babysitter
HEALTH HISTORY FORM
→ no nicknames (exception is for pediatric patients); all data
should be accurate
→ should be reviewed after several months have elapsed; update form should be completed periodically
→ a current, accurate health history serves as a preventive
measure in patient treatment and as a defense in malpractice
suits
HEALTH HISTORY FORM
→
8 ½ x 11 inches, made of heavy paper stock
CLINICAL CHART
→ one side contains a dental chart, a review of the patient’s health history and general patient information
→ the reverse side provides space for entering the treatment plan
and recording services rendered
CLINICAL CHART
→
includes doctor’s diagnosis and the treatment plan
recommended for the patient
→
“fee quoted is an estimate and that unforeseen circumstances
may affect the final fee for the service”
DENTAL DIAGNOSIS AND ESTIMATE FORM
→
contains information about the patient, reason for referral, and
an anticipated treatment plan
→
the consultant returns an evaluation and recommendation on the
form and returns it to the dentist
CONSULTANT AND REFERRAL REPORT
→the blueprint which improves communication between the dentist and the laboratory technician
→ helps eliminate illegal dental practices
LABORATORY REQUISITIONS
→ preventive measure against malpractice suits
→ written summary of the treatment plan, as agreed upon by the
patient and the dentist, dated and signed by both parties
CONSENT FORMS
