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Chapter 26 pt record

the patient record

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