Wk 13: Clinical Records Flashcards

1
Q

why is it important to keep good dental records

A
  1. To aid and enhance patient care
    - Facilitates diagnosis and treatment planning
  2. To help you recall at a later date what events took place and the reasons for your decisions
  3. Ensure continuity of care
  4. Patient Safety
  5. Clinical Governance and Audit purposes
  6. Forensic identification purposes
  7. Medico-legal purposes
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2
Q

What is included in the history component of an 011

A

Chief complaint
history complaint
medical history
dental history
relevant social history

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3
Q

What’s included in the examination portion of an 011

A

Extra oral
-lymph nodes, glands, symmetry,tmj

intra oral
-CPITN, Hard tissues, soft tissues

  • generation of an odontogram
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4
Q

What is included in the assessment portion of an 011

A

Radiographs, special test, diagnosis

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5
Q

What is included in the information and discussion of an 011

A

Treatment options given
-risks, benefits, advice,

Treatment declined

informed consent obtained

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6
Q

What is included in the treatment plan section of an 011

A

Written organized treatment plan

treatment carried out
- post op instructions
- adverse reactions
- steps of treatment

Prescriptions
- drugs and laboratory

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7
Q

What is included in the follow up portion of an 011

A

Treatment to be performed and when

further actions (referrals

Recall intervention

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8
Q

Describe what an 011, 012,013, 022, 114

A

011- comprehensive oral exam
012- periodic oral exam
013- limited oral exam
022 Intra oral xray
114- Removal of calculus (first visit)

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9
Q

what does CASE stand for

A

CLEAR
ACCURATE
SUFFICIENT
EFFICIENT

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