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Dental
Records Management
| Question | Answer |
|---|---|
| A patients health record in formation is protected by what law | HIPAA |
| Per HIPAA law, can red stickers be placed on the outside of the chart with medical information | No |
| Is it necessary for the Dental Auxiliary to check the health history for each visit once it has been completed | Yes |
| In accordance with HIPAA, every patient must sign an acknowledgement that she has received the notice of___________ practices. | Privacy |
| Patient records must be kept in a physically secured area and are considered to be what? | Legal Documents |
| Is is illegal for a dental professional to ask a patient her place of employment? | No |
| Does the dental office need permission to fax patient records to a referring specialists without their consent | Yes |
| To facilitate correction of error entries, it is acceptable to write in the patients chart using a pencil | F |
| Dental assistants should be aware of the laws regarding their duties for the state in which they practice | T |
| What is the primary purpose of HIPAA | To protect patient confidentiality and to assure that patients know what is done with health information. |
| Dental records involving patient care belong to who? | The dentist |
| When an office is paperless, is there still a hard file of the dental chart | No |
| How many years does the state law mandate that a dental patient record be kept? | 7 years |
| What is the legal procedure for correcting an incorrect entry in the chart? | Draw one line through the entry |
| When writing in the patient's dental record, the acceptable method is to use an | ink pen |
| The office staff would need what in order to send a request for a copy of the patient record even to another dentist | written permission |
| Forms in the patients record are maintained in what order with the most recent information on top | chronological |
| What is the minimum information kept for every patient contain? | Name, date of birth, address, emergency contact phone numbers, employment, and attitude toward dentistry including expectations of care. |
| The patients dental history should include valuable information such as what | The patients recall history, a record of the patients previous dental care, and the dates of the patients last treatment |
| How often should the patient update their medical history | Each time the patient returns to the office for an appointment |
| What two colors of pencil are used to chart on a manual dental chart | red and blue |
| where is a signed informed consent for treatment kept | in the patients chart |
| Another name for the dentist evaluating and assessing plus diagnosing the dental disease of a patients oral cavity which becomes the treatment plan can also be referred to as a___________ | Care Plan |
| A periodontal exam consists of what | taking six measurements of each tooth sulcas and recording the depths |
| The extra oral/intraoral exam involves the observation and palpation of what | The neck, the face and lips and the oral cavity |
| What is the chief concern | What prompted the patient to seek the dentist |
| Progress notes include what | Date of treatment, tooth treated, medications and treatment performed |
| A disadvantage to using an electronic patient chart is that there isn't a universal ____________set within the United States that all dentists must follow | Policy |
| What armamentarium is required for a complete oral examination | gauze squares, mouth mirror, explorer, periodontal probe and articulating forceps and paper. |
| what does SOAP stand for | Subjective, objective assessment and plan |
| Language used to chart patient information should always be | Objective and unemotional |
| Acceptable information listed in progress notes should include | Broken or cancelled appointments, compliance issues, and conversations regarding treatment |
| The information on the patients medical history is important and usually includes information including what | drugs and interactions, existing medical problems, bleeding problems and allergies |
| Why is it important for the dental assistant to meet with the patient and verbally discuss and complete the medical history? | By asking questions and listening, the assistant can integrate the patients health history and oral findings |
Created by:
mkempf073162
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