Patient Records, Assessment, and Treatment Planning Support
Core concepts
Accurate records support diagnosis and continuity of care. Know the components of a dental record: medical and dental history, chief complaint, clinical findings, periodontal charting, radiographs, photographs, models, and treatment notes. Understand the purpose of informed consent documentation, progress notes, and the legal weight of records. Learn how to record vital signs, allergies, medications, and risk factors. Treatment planning support involves organizing findings, presenting options, and documenting the patient's decisions and referrals.
Traps to watch
Questions test documentation standards: records must be objective, dated, signed, and contemporaneous. Avoid subjective or judgmental language. Another trap is confusing the assistant's role with diagnosis - assistants gather and record data but do not diagnose. Informed consent traps involve assuming a signature alone is sufficient; consent requires discussion of risks, benefits, alternatives, and the patient's questions. Also know that corrections to records should be made without obliterating the original entry.
Worked rule of thumb
Write notes as if they will be read in a legal proceeding: who, what, when, where, and why. Example: instead of "patient seemed nervous," record observable facts such as "patient reported anxiety; vitals recorded; procedure paused and resumed after discussion."
Organization and confidentiality
Keep records secure, release only with proper authorization, and follow retention requirements.