BACKGROUND
The Patient Record is a legal document. The record
contents stand up in a court of law as legal evidence, therefore each record
should be kept in good working order. As part of our program of Continuous
Quality Improvement, every student will be required to audit each of the
records in their patient families. Seniors, as a reminder, all chart
audits must be completed and checked by your respective Dental Care Coordinator
prior to issuance of your diploma.
Following is a walk-through guide to completion of the Chart Audit, followed by a sample audit form.
ORGANIZING THE PATIENT RECORD
1. Front Jacket
--Patient Identification
tag clearly states the patient name, address, SSN#, date of birth, phone
number
--This tag should be accompained
by a similiar bar code tag
**If missing either tag, or in need of replacement contact Patient
Records
--The blue stamp indicating
that the patient has received the Patient Informaiton Booklet, should be
initialed and
dated.
If not please distribute booklet at next appointment.
--Any Medical Alerts should
be clearly indicated.
2. Inside Front Pocket
--This pocket should contain
any miscellaneous non-treatment related papers (e.g: Change of Address,
Insurance)
3. Section I (in the following order)
--Emergency Form (red printed
form which indicates current medications and emergency contacts)
--Medical Clearance Letters
/ Medical Correspondence
--Problem List
--Medical History Update
--Soft Tissue Exam
--Medical History Initial
Assessment
--Oral and Dental History
Questionaire
--Medical History Questionaire
4. Section II (in the following order)
--Initial Exam and Findings
--Consultations
5. Section III (in the following order)
--Referral / Reassignment
Requests
--Case Completion or Case
Discharge
--Treatment Plan
6. Section IV (in the following order)
--Progress Notes
7. Section V (in the following order)
--Periodontal records
--Endodontic records
--Oral and Maxilofacial
Surgery Records
--Removable / Fixed Design
Records
8. Section VI (in the following order)
--Radiographic Order and
Exposure Record
--Agreement / Consent to
Surgical Procedures
--Consent to treatment
--Agreement / Consent to
examination
9. Back Pocket
--Radiographs
--Patient file copy of Removable
/ Fixed laboratory scripts
Please Note--copies of posted ATF /PFF need not be kept in the patient record, please disgard. Also file any treatment related loose papers with the corresponding discipline section.
The State University of New York
School of Dental Medicine
CHART AUDIT
CHART #_________________ DATE_________________
PATIENT NAME________________________________
ASSIGNED TO__________________________________
Items, which are circled in red, require student remediation.
Please return chart
And form to you respective Dental Care Coordinator once remediation
is complete.
MEDICAL HISTORY
* Signatures- patient, student / faculty
* Dated
CONSENT FORMS
* Signatures- patient, student / faculty
(TO EXAM)
* Dated
(TO TREAT)
TREATMENT PLAN
* Signatures / stamp—patient faculty student
* Dated
PROGRESS NOTES
* Signatures / stamp—Student faculty
* Dated entries
* Legible entries
* Patient name and File # on each page
RADIOGRAPHS
* Mounted radiographs are appropriately:
Dated? Identified?
* Mount any radiographs which are in coin envelopes
o Only if dated and identified
* Loose, unidentified radiographs are to be placed in
envelope labeled-Undocumented Radiographs
PATIENT INFORMATION
* Distribute –patient to initial and date jacket cover
BOOKLET
May 2001
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