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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Da117 practice management

DA117Practice Management

Records Management


Misfiling

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

Patient charts contain

  • Medical and dental histories

  • Exam and treatment records


Da117 practice management

  • Correspondence related to patient care

  • Prescription and lab orders

  • Radiographs


Da117 practice management

  • 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

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

Reasons for Transfer

  • Change of dentist

  • Relocation

  • Dentist to consult with another dentist

  • Referral to a specialist


Da117 practice management

  • Must have written consent from patient to transfer records


Transfer records without written consent

Transfer records without written consent

  • Court order – Child abuse, elder abuse

  • Domestic violence

  • Military

  • Insurance fraud

  • Workman’s compensation


Alphabetizing indexing units

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

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

Categories of Records

  • Vital – Can not be replaced

    • Patient’s clinical record

    • Deed to office


Da117 practice management

  • Important – Valuable but not vital

    • Accounts payable receivable records

    • Cancelled checks

    • Inventory and payroll records


Da117 practice management

  • Useful – Different in each office

    • Employment applications

    • Expired insurance policies

    • Petty cash vouchers


Da117 practice management

  • Unimportant –

    • Notes

    • Memos


Types of records

Types of Records

  • Clinical –

  • Information regarding patient treatment

  • Registration form

  • Health history – no blanks

  • Consultation/referral reports

  • Consent forms


Da117 practice management

  • Financial

    • End of day reports

    • End of month reports

    • Payroll reports

    • Paid bills


Life cycle of records

Life Cycle of Records

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


Da117 practice management

DISTRIBUTION – Chart given to doctor for diagnosis


Da117 practice management

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


Da117 practice management

  • MAINTENANCE – Should information be saved?

  • DISPOSITION – Chart destroyed or stored permanently


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