Dental Records, Medical History & Charting

• In what order should a 6 point pocket chart be completed?

  Start on the maxillary teeth, doing the buccal measurements first, moving around to the palatal measurements of the maxillary teeth. Then move onto the buccal measurements of the mandibular teeth, around to the lingual measurements of the mandibular
• What is a 6 point pocket chart used for?

  It's used to measure the pocketing around individual teeth for patients with periodontal disease.

  - It measures around the distal, mesial, buccal, lingual & labial surfaces of each tooth and it also measures gum recession, bleeding, tooth mobility and bone loss
• What will be completed if the patient's gingival health isn't good?

  A 6 point pocket chart
• What is a basic periodontal examination and what does it involve?

  It's a basic exam to check gum health and you measure the pockets around the gums in sextants.

  
  

  To qualify for recording, the sextant must have at least 2 teeth present
• What are the Salud notations used in dental charting?

  
• What are some written notations used in dental charting?

  
• why has the FDI charting system been recommended more than the Zsigmondy-Palmer System?

  to allow easy transmission of dental information on forms
• What are the 2 systems of dental charting commonly used?

  1. The Zsigmondy-Palmer System

  (coverts the tooth into one corner of the quadrant groups)

  
  

  2. The FDI (Federation Dental Internationale)

  (uses numbers)
• in what way should you complete a chart?

  as if you are looking at a patient from the front
• Charting

  
  

  what is a Dental Chart?

  A diagrammatic representation of the teeth in a patient mouth, showing all surfaces of the teeth.

  
  

  The chart will be used to show: teeth present, teeth missing, work to be carried out and work completed
• Dental Records and Medical History

  
  

  What is information governance?

  The way in which the NHS handles all of its information like Patient Records
• Dental Records and Medical History

  
  

  Why is it so important to have good record-keeping?

  Because dental records are legal documents and are therefore legally binding: 'if it isn't clearly written down, it didn't happen
• Dental Records and Medical History

  
  

  What are the Salud, Romexis and EPR (computer systems) expectations?


  • Salud still forms part of the Patients health record

  • Do not share log in details

  • Do not leave patient details on screen, minimise or

  log out

  • Always log out at the end of a session

  • Patient or confidential information should only be

  stored on Salud and must not be saved onto the local computer desktops, shared drives or USB sticks
• Dental Records and Medical History

  
  

  What are the expectations when going to write patient's notes?

  • All entries should be written in black ink

  • Every entry must be legible

  • Every entry must have the Date and Time

  • Your name in block capitals and your group no.

  • Your signature

  • Countersignature from the clinical supervisor

  • Each page front & back must have the:-

  • Patient's name

  • Hospital number

  • Date of birth

  • Corrections must be crossed through with a single line, signed and dated

  (you must not use correction fluid)

  • Clear and accurate records of discussions you have, assessments made, treatment and medicines you give

  • Should complete records as soon after the event as possible

  • You must not tamper with the original records in any way

  • You must ensure any entries that you make in the patient's

  records are clearly & legibly signed, dated & timed

  • You must ensure all records are kept securely

  • Do not use jargon or slang

  • Remember to distinguish between opinion and fact

  • As a dental student, all your entries should be count
• Dental Records and Medical History

  
  

  you should be mindful of the what and where of conversations

  you have about patients

  TRUE/FALSE

  TRUE
• Dental Records and Medical History

  
  

  Why is it important to write only true and accurate notes?


  Because patients have a right to request access to a copy of the records (not to mention you shouldn't be writing anything untrue or inaccurate anyway)
• Dental Records and Medical History

  
  

  How do you keep patient notes safe?

  Have password protected electronic records and locked storage for physical records
• Dental Records and Medical History

  
  

  Who should private and personal records be viewed by?


  Those involved with the patient care
• Dental Records and Medical History

  
  

  What electronic system is used at Guy's Hospital for patient notes and record keeping?

  Salud
• Dental Records and Medical History

  
  

  What information should you record in patient notes?

  • Patient demographics (name, DOB, address, etc...)

  • Medical history and medications - current and those you may

  prescribe or administer

  • Dental history and previous treatment

  • Assessment records, treatment op#ons and plans and any

  treatment carried out

  • Discussion and conversations - those in person and any

  telephone conversations

  • Lab prescriptions

  • Photographs and radiographs

  • Consent forms
• Dental Records and Medical History

  
  

  What are patient records?

  Any information that is relevant to a patient and their care, whether it be paper-based or electronic