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Records Management

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