Wk 13: Clinical Records Flashcards
why is it important to keep good dental records
- To aid and enhance patient care
- Facilitates diagnosis and treatment planning - To help you recall at a later date what events took place and the reasons for your decisions
- Ensure continuity of care
- Patient Safety
- Clinical Governance and Audit purposes
- Forensic identification purposes
- Medico-legal purposes
What is included in the history component of an 011
Chief complaint
history complaint
medical history
dental history
relevant social history
What’s included in the examination portion of an 011
Extra oral
-lymph nodes, glands, symmetry,tmj
intra oral
-CPITN, Hard tissues, soft tissues
- generation of an odontogram
What is included in the assessment portion of an 011
Radiographs, special test, diagnosis
What is included in the information and discussion of an 011
Treatment options given
-risks, benefits, advice,
Treatment declined
informed consent obtained
What is included in the treatment plan section of an 011
Written organized treatment plan
treatment carried out
- post op instructions
- adverse reactions
- steps of treatment
Prescriptions
- drugs and laboratory
What is included in the follow up portion of an 011
Treatment to be performed and when
further actions (referrals
Recall intervention
Describe what an 011, 012,013, 022, 114
011- comprehensive oral exam
012- periodic oral exam
013- limited oral exam
022 Intra oral xray
114- Removal of calculus (first visit)
what does CASE stand for
CLEAR
ACCURATE
SUFFICIENT
EFFICIENT