EXAM 3: Documentation for Dental
Hygiene Care And Complete Solutions.
Forms/ways of documentation (8) - Answer - Hand-written
- Electronic
- Chronological
- Systemic
- Comprehensive
- Accurate
- Unaltered
- Signed by dental hygienist
Essentials of ethical record keeping (6) - Answer - Privacy
- Confidentiality
- Security
- Accuracy
- Authenticity
- Impersonal/objective
Privacy explanation - Answer Patient's right to control access to identifiable personal health
information
Confidentiality explanation - Answer The responsibility of the healthcare provider to protect patient's
information
Security explanation - Answer Protection against unsecured patient data
Accuracy explanation - Answer Recorded information is not altered after the fact
, Authenticity explanation - Answer Only data actually obtained during the patient visit is recorded
Impersonal/objective explanation - Answer Personal opinion or negative social observations not
pertinent to the patient's treatment are never placed in the patient record
The patient record- communication - Answer Communication between staff members and with
patients
The patient record facilitates what? - Answer Planning and continuity of care
The patient record is the basis for what? - Answer Evaluation of quality care
The patient record data from health records can be means and evidence of what? - Answer (means) -
Research and education
(evidence) - Legal evidence in legal or forensic situation
The patient record: Documentation (4) - Answer - Authentic
- Accurate and comprehensive
- Legible
- Objective
The patient record: Entries (4) - Answer - Recorded promptly during/following treatment
- Clear, concise, subjective statements
- Dated
- Signed by clinician
Components of a patient record (3) - Answer - Varies among private practices/clinics
- All info collected is official part of permanent records
- All components of DH process of care are addressed
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