Chapter 36 Dental records management

Facts

Accuracy is very important All charts and documents must be filled out

completely. Dental records and patient charts are legal

documents.– Can be used in court.

Blue or black ink. Do not erase or use white out.

Facts Active patients:TX within last two years. Inactive patients: NO Tx 3+ years. Must keep charts minimum 7 years after becoming

inactive. Must properly dispose of. (shred) Always maintain confidentiality.

– Use caution when emailing or faxing patient information.

– Do not leave open on the front desk.

Tickler file

Is NOT used to determine when to tickle your patients!

It IS a reminder of tasks that are not done on a regular basis or need to be completed by a certain date.

Usually an index box with 3 X 5 index cards. Computer has built in tickler file. (pop-up

reminder).

Equipment and supplies

File folder aka patient chart– book style or envelope style.– should provide ease of use.– secure and protect patient info.

Equipment and supplies

File cabinets– vertical (2 or 4 drawers)– open shelf lateral, (down the wall)– moveable.

Chart filing

Alphabetical– most common

• Last name (surname), first name (given name) then middle initial.

Numerical– filed by an ID#

• generally used at practices with more than 20,000 patients.

Chart filing

Cross-reference – filed alphabetically and numerically.– Can access with a name or account #

Chronological– filed into time spans

• usually months and days, used for recall.

Subject– business filing or specialists for referrals.

Alphabetical filing

Patients name is divided into 3 units:• Last name = surname• first name = given name• middle name/initial = given name.• Shorter name goes first.

– Rob Smith goes before Robert Smith– same name, go by middle initial– Jr. goes before Sr.– the II which goes before III– titles go last. Sister, Father, Doctor– a hyphenated name is one long name

Alphabetical filing

Requires accuracy during placement and removal

Can use an ‘out guide’ to ease re-filing.– Like a book-mark/placeholder for your chart.

Color coding Reduces # of errors and lost charts. much quicker and easier.

– Charts with same letter in name will be the same color.

– Can use colored tabs with colored charts or on plain yellow charts.

Aging/purging/date tabs

Color coded tab with year printed on it.– Speeds locating/sorting of active vs. inactive

charts.– A new sticker is placed on the chart each year

the patient visits the office.

Patient chart info

Includes– x-rays, medical history, chart notes, lab slips,

and prescription history.– Does not include

• financial records, payment history, insurance information. These are ‘business records’.

Chart write-ups aka chart notes. manually (writing notes) can be done by the:

– doctor– assistant– receptionist

computer– typed as needed– auto-chart notes

• Dr/assistant puts info in computer 1X• one mouse click puts info into pt. chart

Chart write-ups

S.O.A.P. format– S = subjective: pt opinion of what is wrong

– O = objective: your opinion of what is wrong

– A = assessment: the doctors diagnosis (Dx)

– P = plan / procedure: treatment (Tx) given

Example of the SOAP format

– S: cc: pt. c/o H+C sens. URQ x 1mo.

– O: ck. Med. hx, PA + BW x-ray taken of URQ, clinical ex reveals poss. caries #3. PA shows deep caries, poss. pulp involvement. PARL noted on MB root.

– A: #3 presents with deep occlusal caries. Dx: irreversible pulpitis w/ PA abscess of MB root.

Example of the SOAP format

– P: PARQ w/ pt. Tx options 1. no Tx. 2. RCT/BU/FGC. 3. EXT. Consent obtained, 2 carps lido 2% 1:100k epi. Luxate w/ elevator, ext w/ 150 focep. Curette socket, irri w/ sterile H2O, place gauze pack, POIG. NV. PO ck x 1wk. Dr’s/Assis initials

• what is PARQ ?

P.A.R.Q.

P = procedures

A = alternatives

R = risks

Q = questions

Transfer of patient chart.

Actual chart– paper and material

belong to the dentist

– information and images belong to the patient

– patients may request a copy of their chart

– cannot refuse the request.

Original stays in the office.– Copy information

– duplicate x-rays

– pt. can pick up

– or send by mail

– Must have consent, or sign a release.

– Some offices charge a fee. (optional)

Computer charting

Efficient! Easy! Neat (no sloppy handwriting) Very organized. Can be combined with

– digital x-ray– front office software.

Must be backed up (saved to disk) daily

Closing

Charting and filing are very important parts of your job. Accuracy matters, spelling counts.

If you are unsure of where something goes, or how to do a task, ask.

Any questions??????