DT The Dental Record: Documenting and Maintaining a Record of Patient Interactions
You will receive 1 unit(s) of continuing education credit upon successful completion of this course. The purchase price of this course is $38.00

Description:

The dental record, or patient chart, holds information about patient interactions and is a vital part of the operation of the dental practice. The Dental Record: Documenting and Maintaining a Record of Patient Interactions is a course that explains the components of the dental record and describes how to deal with dental record.


Author:
American Dental Association, Continuing Education and the Council on Dental Practice and Product Development and Sales
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Learning Objectives:

Upon completion of this course, participants should understand how to:

  1. Document each patient interaction in the dental record
  2. Maintain accurate, complete dental records
  3. Maintain up-to-date patient health histories
  4. Obtain necessary permissions, such as informed consent or release forms
  5. Provide copies of, or transfer, patient records
  6. Transition to digital recordkeeping


Abstract:

The Dental Record, also called the patient chart, can be used in many ways to help run the dental practice. Some the these ways are: evaluating the quality of care that is provided to the patient, providing a means of communication between the treating dentist and any other doctor who will care for that patient, serving as a document to be used in a court of law to establish the diagnostic information that was obtained and the treatment that was rendered to the patient,
providing information on forensic odontology, helping to determine whether the diagnosis and treatment conformed to the standards of care in the community.

The components of the dental record include both administrative and clinical information such as:

  • Database information (name, address, contact information)
  • Dental insurance information
  • Radiographs
  • Referral letters and consultations with referring or referral dentists
  • Medication prescriptions including type, dose, amount, directions for use and number of refills

Other important information about how to use the dental record are: information about HIPAA rules on protecting health information and information about health/dental history forms.
The course also includes a glossary of dental terms.



Outline:
  1. Importance of the Dental Record
  2. Components of the Dental Record
  3. Retention of Records
  4. Transfer of Copies of Records
  5. Ownership of the Dental Records
  6. Destruction of Records
  7. Health/Dental History Form
  8. Informed Consent
  9. Informed Refusal
  10. Use of Social Security Number
  11. Digital Technology and Patient Records
  12. Communications with Patients by E-mail
  13. Making the Transition to a Paperless Office
  14. National Health Information Infrastructure
  15. HIPAA /Protecting Health Information
References:
  1. Fast-Track Training: The Basics for Dental Staff. Chicago: American Dental Association; 2007.
  2. ADA Principles of Ethics and Code of Professional Conduct, http://www.ada.org/prof/prac/law/code/principles_01.asp, accessed January 26, 2007.
  3. Commercial Shredders. http://www.naidonline.org/members.html
    American Dental Association; 2004: 61-62.
  4. Employee Office Manual: A Guide for the Dental Practice. Chicago: American Dental Association; 2000.
  5. Use of  SSN. www.privacy.ca.gov/recommendations/ssnrecommendations.pdf.
  6. Frequently Asked Legal Questions: A Guide for Dentists and the Dental Team. Chicago: American Dental Association; 2004: 61-62.
  7. HIPAA Security Kit. Chicago: American Dental Association; 2004.






American Dental Association is an ADA CERP Recognized Provider.

ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry.