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Chapter 26 pt record
the patient record
| Question | Answer |
|---|---|
| to bring attention by making someone aware | alert |
| process of making an official evaluation of someone or a particular situation | assessment |
| persisting over a long time | chronic |
| arranged according to time of occurrence earliest to most recent | chronologic |
| personal information about patients that includes address phone work information also statistical characteristics of populations | demographics |
| identification or determination of the nature and cause of a disease or injury through evaluation of a patient's history and examination findings | diagnosis |
| pertaining to the establishment of the identity of an individual on tha basis of scientific methods | forensic |
| the health insurance portability and accountability act of 1996 describes the federal regulations that ensue privacy regarding a patients healthcare information | HIPPA |
| act of initiating legal proceedings as in a lawsuit | litigation |
| program in place for monitoring and evaluating a project service or facility to ensure that standards of quality are being met | quality assurance |
| act of completing forms by providing personal information | registration |
| what is the most important document that is maintained for each patient in a dental practice | the patient record |
| information gathering forms are compleed by the patient with the assistance of the business assistant before any treatment is provided These include the following | patient registration,medical-dental health history form,medical later information form,consent forms |
| The dentist, dental assistant or dental hygienist completes the disgnostic information gathering forms whcih are the | physical examination form,radiographic examination, and clinical examination |
| what is considered a permanent document of the dentist, is a legal document and can be used as evidence in a legal settlement or lawsuit or as a reference tool in a forensic case | patient record |
| how often should a patient update the medical health history form | everytime they go to the dentist.` |
| what form is the most detailed document in the patient record | the clinical examination form |
| once the dentist has reviewed the medical -dental health history form and has dictated any charting or updates needed on the clinical examination form he or she then records the plan of care on what form | treatment plan |
| what section of the record is where treatment is recorded with the date tooth number and treatment | progress notes |
| what color of pen should you used to write your progress notes? | black ink pen |
| how do you correct an error on a patient's record | using an ink pen,draw a single like through the previous entry initial and date the change |
Created by:
cynthia.fryer
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