Dental Record Keeping (5th Ed)

Course overview

The dental record is the official document that houses all pertinent information about a patient receiving care in a dental practice. It archives historical and diagnostic information, as well as details diagnoses, treatment plans, consents to treatment, and the specifics of care provided. A properly constructed and maintained dental record allows concise and efficient communication between the dentist and the patient, as well as between the dentist and other health care professionals. A well-documented record may be the dentist's best defense in a case of alleged malpractice and may serve as a key component of a forensic investigation. This Guide provides straightforward, concise guidance in constructing and maintaining a dental record that will meet contemporary standards of care, as well as federal patient privacy standards. Since general dentists often find it difficult to document occlusal status in an efficient manner, a helpful "Rapid Occlusal Assessment" template is provided as an appendix.