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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

DA117Practice Management

Records Management

  • 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
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
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
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 I Surname
  • Unit II Given Name
  • Unit III Middle name
  • Unit IV Senority, degree, titles
  • Common Errors
  • Macneal McNeil
  • St. John Saint John
  • Hyphenated last names. i.e. – Brown-Smith
  • 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
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
types of records
Types of Records
  • Clinical –
  • Information regarding patient treatment
  • Registration form
  • Health history – no blanks
  • Consultation/referral reports
  • Consent forms
    • 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?
MAINTENANCE – Should information be saved?
  • DISPOSITION – Chart destroyed or stored permanently