Dental Record Notes

- “Dental Record was created by the Wisconsin Dental Association to provide dentists with a quality dental record system.”
- Charting System
o Complete Record – contains 14 forms of clinical, legal, financial and administrative records.
o Flexible Record – contains 2 dividers, 2 pockets 8 popular forms. Then a choice of 4 additional tablets of forms that work best for any practice.
o Basic Record - Eight basic forms, which covers the most essential record keeping requirements with the option to supplement with additional forms at any time.
o Children’s Record - Seven basic forms in this package address the unique record keeping needs of children from infancy through adolescence. The Children’s Record may be converted to the Complete Record when the child becomes an adult.
o Emergency Record - offers a unique, compact, “pocket folder” that covers all your essential record keeping needs for your single-visit patient. The chart provides areas for registration, patient history, doctor's notes, insurance, release, and consent. This amazing chart can be filed in its own Emergency Record cabinet offered by The Dental Record or inserted directly into any of the other Dental Record charts
- Dental Records should contain components specified in the following subparts:
o Personal Data – Name, birth date, address, parents/guardian if minor, and emergency contact’s name and number.
o Dental and medical History - information from the patient or the patient's parent or guardian on the patient's dental and medical history. The information shall include a sufficient amount of data to support the recommended treatment plan.
o Reason for visit – Include patient’s stated oral health care reasons for visiting the dentist.
o Clinical examination progress notes –
• Description of clinical examination, tests conducted and diagnosis.
• Plan of intended treatment.
• Description of services rendered and any treatment complications.
• Description of all radiographs, study models, and periodontal charting if applicable.
• Name of, quantity of, and strength of all drugs dispensed, administered, or prescribed.
• Name of dentist, dental hygienist, or any other auxiliary, who performs any treatment or service or who may have information regarding a patient.
- Informed consent – documentation of informed concent which includes discussion of procedure(s), option, potential complications and known risks and patient’s consent to proceed with treatment.
- Retention of records – a dentist shall maintain a patient’s dental record for a minimum of 5 years after the last date of examination, prescribing or treatment.
Electronic record keeping - When electronic records are kept, a dentist shall keep either a duplicate hard copy record or use an unalterable electronic record.


Source:
http://www.dentalrecord.com/about.cfm
http://www.wda.org/professional/association/member_benefits/dentalrecord.asp
http://www.uiowa.edu/~iowaperi/IBDErecord.htm