NOT INCLUDED - Week 9 - Introduction to patient evaluation and treatment planning Flashcards
(14 cards)
What are the notional board expectations about maintaining health records set out in your profession’s code of conduct
- You must keep good health records
- Good processes support good health records
- Continuity of care is an important part of making and keeping good health records
- Health records must be kept private and confidential
- Patients have a right to access information in their health records
explain 1. You must keep good health records
- Must be objective and show respect for patients
- Include clinical history, diagnostic, treatment and service information and advice
- Should clearly identify the date and time service was provided
- Consent
Explain 2.Good processes support good health records
- Make records at the time or as soon as possible afterward to make sure its accurate
*checking available electronic records such as My Health Record should be part of your process in taking the patient’s history
*keep billing information accurate and up to date
who needs to follow these guidelines
- Dentist
- Dental prosthetists
- Dental hygienists
- Dental therapists
- Dental specialists
- Oral health therapists
These guidelines address how dental practitioners should maintain dental records
dental practitioners have a professional and legal responsibility to:
- keep as confidential the information tey collect and record about patients, clients or consumers
- retain, transfer, dispose of correct and provide access to dental records in accordance with the requirements of the laws of the relevant state, territories and common wealth
- assist patients, clients or consumers to make well informed decisions about treatment procedures and not force treatment on patients (or mislead), clients or consumers without their consent
what are the different patient evaluations
- comprehensive oral examination
- periodic oral examination
- oral examination (limited)
what are the different ways to gather patient information
- Patient history
- Clinical examination
- Radiographic examination
- Other diagnostic aids
- Documentation
Gathering and recording information about the patient often requires more time and attention than any other aspect of treatment planning
To prevent missing important findings, the dentist should gather data in an organized systematic manner
what are the 2 most important aspects of the patients assessment process
- history taking
- clinical examination
what are the difference between symptoms and signs
- Symptoms – verbally revealed by the patient (pain, swelling, bleeding, broken teeth)
- Signs – discovered by dentist during examination (swelling, bleeding, cavitations)
what are different methods to take patient history
- Questionnaires and forms
- Patient interviews
what are advantages of questionnaire forms for taking patient history
- Timesaving
- No special skills required standardized
what are disadvantages of questionnaire forms for taking patient history
- Limited information collected
- Severity not recorded
- Misinterpretation of question leading to incorrect answer provided
- Incomplete information revealed
What is patient interviewing as a method for taking patient history
- Required excellent communication skills to adapt to various cultural, gender and socioeconomic backgrounds
- Use a language translatory if necessary
- Tailor questions to the individual patient
- Serves a problem solving function
- A formal discussion
- Systematic and unbiased information gathering
Aim: development of a good rapport with the patient by establishing a cooperative and harmonious interaction
Includes open and closed questions
What are the stages of treatment planning
- emergency (urgent) phase
- Preventive (disease control) phase
- Restorative phase
- Re-evaluations phase (patient response to the treatment)
- Definitive phase-provide complex treatment)
- Recall and review phase (maintenance)
- Prognosis and long term care
