Da117 practice management
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DA117 Practice Management. Records Management. Misfiling. The most common cause of missing patient records Dental assistants help out the front desk by pulling and filing charts, but must know proper alphabetical filing techniques. Patient charts contain. Medical and dental histories

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DA117 Practice Management

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DA117Practice Management

Records Management


Misfiling

  • The most common cause of missing patient records

  • Dental assistants help out the front desk by pulling and filing charts, but must know proper alphabetical filing techniques


Patient charts contain

  • Medical and dental histories

  • Exam and treatment records


  • Correspondence related to patient care

  • Prescription and lab orders

  • Radiographs


  • Patient charts are legal documents and involve confidentiality issues.

  • Contents are owned by the dentist but patient must be allowed access to their own record.


Transfer of Records

  • Originals are always kept by the dentist and copies are sent out.

  • Original xrays are kept by the office and duplicates are sent out


Reasons for Transfer

  • Change of dentist

  • Relocation

  • Dentist to consult with another dentist

  • Referral to a specialist


  • Must have written consent from patient to transfer records


Transfer records without written consent

  • Court order – Child abuse, elder abuse

  • Domestic violence

  • Military

  • Insurance fraud

  • Workman’s compensation


Alphabetizing = Indexing Units

  • Unit ISurname

  • Unit IIGiven Name

  • Unit IIIMiddle name

  • Unit IVSenority, degree, titles

  • Common Errors

  • MacnealMcNeil

  • St. JohnSaint John

  • Hyphenated last names. i.e. – Brown-Smith


Protection

  • Originals must not be taken out of the office

  • When not in use, put in proper place

  • Return to filing system at the end of the day

  • Pack records tightly together, slows fire damage

  • Close and lock all filing cabinets

  • Back up computerized records


Categories of Records

  • Vital – Can not be replaced

    • Patient’s clinical record

    • Deed to office


  • Important – Valuable but not vital

    • Accounts payable receivable records

    • Cancelled checks

    • Inventory and payroll records


  • Useful – Different in each office

    • Employment applications

    • Expired insurance policies

    • Petty cash vouchers


  • Unimportant –

    • Notes

    • Memos


Types of Records

  • Clinical –

  • Information regarding patient treatment

  • Registration form

  • Health history – no blanks

  • Consultation/referral reports

  • Consent forms


  • Financial

    • End of day reports

    • End of month reports

    • Payroll reports

    • Paid bills


Life Cycle of Records

  • CREATION – Begins with patient registration and health form – Is patient permanent or emergency only?


DISTRIBUTION – Chart given to doctor for diagnosis


  • USE – Evaluation of data – Diagnose, treat or refer?


  • MAINTENANCE – Should information be saved?

  • DISPOSITION – Chart destroyed or stored permanently


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