The patient record is the most important document maintained for each patient in a dental practice (Fig. 26-1). Whether you are communicating with a patient by phone or in person, the patient record must be available to refer to. A patient’s record is organized in a specific order to allow the dental team to move from the patient’s personal information, to the diagnostic findings, and then finally to the documentation of treatment.

FIG. 26-1 Example of the patient record. (Courtesy Patterson Office Supplies, Champaign, IL.)

Information-gathering forms are to be completed by the patient with the assistance of the business assistant before any treatment is provided (Fig. 26-2). These include the following:

• Patient registration form (personal patient information)

• Medical-dental health history form (patient’s overall health and dental status)

• Medical alert information form (any medical concerns that need to alert the dental team before treatment)

• Consent forms (Health Insurance Portability and Accountability Act [HIPAA], verification of accuracy, insurance)

FIG. 26-2 Business assistant instructing a patient on completing the forms.

The patient will be escorted to the clinical setting, where the dental assistant or the dental hygienist along with the dentist will complete the following Diagnostic information–gathering forms:

• Physical examination form (posture and gait, vital signs, cognition, and communication skills)

• Radiographic examination (this can include any of the following exposures: periapical, bitewing, occlusal, panoramic)

• Clinical examination form (extraoral examination, intraoral examination, periodontal examination)

Once the diagnostic information–gathering process has been completed, the dentist will formulate an assessment from the findings of oral health status. An assessment is the process of collecting data and then evaluating or drawing conclusions from the findings. During this stage, the dentist will complete the following:

• Assess a patient’s intraoral and extraoral conditions by completing a comprehensive clinical examination

• Review all significant findings

• Present a diagnosis to the patient

• Develop and document a treatment plan with input from the patient

• Schedule a series of appointments by which to complete treatment in a timely manner

• Follow through with maintenance stages of the patient care process.

1 What forms would the business assistant hand to a new patient to complete before he or she is seen for treatment?

2 What term describes the collection of data used to make a correct diagnosis?

Patient Compliance

A patient record contains confidential information related to a patient’s personal background. It is important for the dental team to follow a high standard when documenting and handling this information. Besides its use in the clinical care of a patient, the patient record can have legal significance, of which the dentist and staff must be aware.

Permanent Record

The patient record is a permanent document of the dentist. This permanent document, also considered a legal document, can be used as (1) evidence in a legal settlement or lawsuit; (2) a reference tool in a forensic case for identification of an individual with the use of a patient’s radiographs or study casts; or (3) a reference for appropriate third parties, such as dental insurance companies and government-aided programs.

Privacy

HIPAA requires that all dental practices today have a written privacy policy. This written policy must inform the patient that the office will not use or disclose protected health information (PHI) for any purpose other than treatment, diagnosis, and billing. The privacy policy is prepared in a written format and must be provided to every patient; all patients must review and sign an acknowledgment that they have received notice of privacy practices (Fig. 26-3). This signed acknowledgment is kept in the patient’s record for a minimum of 6 years. See Chapter 4 for additional legal information regarding HIPAA.

Quality Assurance

The dentist will use the patient record as the primary source of information in determining the overall quality of care that a patient receives. Quality is the key word to remember when a patient is receiving dental care.

Does the patient believe that the best and most timely treatment is being provided? This question can be extremely important if the clinical setting is a larger practice with multiple practitioners, or a community dental clinic or teaching institution, where patients may be seen by different dentists. Each dental setting must promote an efficient and effective quality assurance program. Following are examples of ways to provide quality assurance in your dental office:

• Routine forms are completed by each patient and verified with his or her signature and date.

• Timely “recall” of patients is followed to address their dental needs.

• A completed patient record is kept for each “active” patient in the dental practice.

• Documentation includes information on when radiographs were taken.

• Current and up-to-date emergency standards are adhered to by the dental team.

• Current and up-to-date licenses, registrations, and certifications and training of dental team members are maintained.