Quality Resource Guide
l
Dental Record Keeping 4th Edition
5
www.metdental.com
an intraoral and extraoral hard and soft tissue
assessment in addition to traditional dental and
periodontal charting, including documentation
of health/disease status. Personnel in dental
offices should have standardized abbreviations
and symbols to document existing conditions and
findings. They should be employed by everyone
in the office, and kept on file for reference.
As in the medical-dental history, all queries
should be answered. For example, if there is
a query concerning the ears and there are
no remarkable findings, a comment such as
within normal limits (WNL) should be entered.
It is generally accepted that while dental health
professionals are not expected to diagnose all the
potential problems and conditions that can occur
in the head and neck, dental professionals should
recognize aberrations of normal. Any equivocal
or suspicious findings should be objectively
documented and referred for appropriate follow-
up evaluation.
The documentation of findings pertaining to
the teeth should be portrayed as accurately as
possible. With paper and electronic records,
such accuracy may be ensured by carefully
drawing what is seen in the patient’s mouth onto
a tooth chart (odontogram). Digital photography
can capture the original condition of the patient’s
mouth and serial photographs may also be used
monitor specific lesions or conditions for change.
More recently SNODENT terminology has been
implemented as means of codifying diagnostic
and existing conditions.
The clinician should carefully design their
record to allow recording and access to data
in an uncomplicated and efficient manner. The
record should provide a method to record,
analyze and longitudinally assess dental and
periodontal and occlusal status. While most
offices are comfortable with standardized dental
and periodontal charting formats, many offices
struggle with a system to adequately document
occlusal conditions. A template, the Rapid
Occlusal Assessment is included (
Appendix A
)
to provide assistance.
Periodontal Conditions:
Documentation and Diagnosis
The
American
Academy
of
Periodontology
released a revised the classification schema
for periodontal disease in 2018 that included
the diagnosis of periodontal severity and risk
of progression by staging and grading criteria.
Information/data required to stage and grade
periodontal disease includes: probing depths;
bleeding on probing; clinical attachment loss;
radiographic bone loss; and history of periodontal
treatment. This new classification has five stages
and 3 grades of periodontal disease. The dental
record should reflect the diagnostic data and
periodontal classification.
Risk Assessments
Risk Assessments are also part of the patients’ initial
assessment and documentation, to improve the
quality of care and enhance long-term outcomes.
Risk assessments can be for both mutable (factors
that can be modified) and immutable risk (factors
that cannot be modified (age, race, and genetics).
Risk assessment information related systemic
factors, destructive habits, home care, oral cancer,
caries and periodontal disease should be captured
in the patient record. Electronic records can be
interfaced with algorithms to quantify risk level.
See
Appendix B
for an example of risk factors.
Consent for Care
A significant responsibility of the dentist is to
obtain and document informed consent. Consents
can be general in nature and many times will
be “assent” in nature where activities such
as patient exam are implied by the patient’s
presence. Written general consents are beneficial
in documenting patient responsibilities during
therapy and for follow-up professional and
personal care. Written consents may be related to
conditions such as patients with a history of anti-
resorptive medications (bisphosphonates et al.) or
procedures with higher risk (surgery, extractions,
implants, root canals,
et al.
). Written consents are
also recommended for complex care patients.
For
patients who refuse treatment recommendations
that are accepted standards of care, an Informed
Refusal consent should be obtained.
Image Management and/or
Radiographic Image Systems
(RIS)
Oral
healthcare
providers
should
also
be
cognizant
of
Personal
Health
Information
(PHI) contained within clinical image systems.
Standards for imaging in medicine and dentistry
have adopted DICOM (Digital Imaging and
Communication Systems in Medicine) standards.
DICOM imaging files contain metadata. HIPAA
standards for images is the same as data within
patient record systems. Data integrity is required
between two systems if the electronic dental
record and the imaging system from different
vendors and integrated. CAD-CAM systems are
adopting imaging standards that are DICOM
compliant, therefore containing PHI as part of
their files. More recently surface scanning via
CAD-CAM systems and radiographic imaging can
be integrated for surgical planning and treatment.
As dental laboratory creation processes move
from analog to digital, access and maintenance
of this information/data must also be part of the
patient record and should follow imaging data
management protocols.
Implanted Material and
Devices
The FDA requires manufacturers of implanted
devices to assign a unique device identifier
(UDI) to their products. It is suggested that
documentation for implanted devices and materials
contain information on the item’s manufacturer,
description of the device, lot number and catalog
reference number. Electronic records can place
these entries in databases, allowing rapid
searching and reporting on devices and materials
utilized in patient care.
Rapid Occlusal Assessment
The Rapid Occlusal Assessment template consists
of series of baseline questions and examination
findings that may be utilized to assist the clinician
in identifying those patients at greatest risk for
occlusion-related problems. Documentation of this
baseline information is especially valuable when
the planned treatment will affect the patient’s