DA117 Practice Management

1. DA117Practice Management Records Management

2. 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

3. Patient charts contain • Medical and dental histories • Exam and treatment records

4. Correspondence related to patient care • Prescription and lab orders • Radiographs

5. 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.

6. 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

7. Reasons for Transfer • Change of dentist • Relocation • Dentist to consult with another dentist • Referral to a specialist

8. Must have written consent from patient to transfer records

9. Transfer records without written consent • Court order – Child abuse, elder abuse • Domestic violence • Military • Insurance fraud • Workman’s compensation

10. 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

11. 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

12. Categories of Records • Vital – Can not be replaced • Patient’s clinical record • Deed to office

13. Important – Valuable but not vital • Accounts payable receivable records • Cancelled checks • Inventory and payroll records

14. Useful – Different in each office • Employment applications • Expired insurance policies • Petty cash vouchers

15. Unimportant – • Notes • Memos

16. Types of Records • Clinical – • Information regarding patient treatment • Registration form • Health history – no blanks • Consultation/referral reports • Consent forms

17. Financial • End of day reports • End of month reports • Payroll reports • Paid bills

18. Life Cycle of Records • CREATION – Begins with patient registration and health form – Is patient permanent or emergency only?

19. DISTRIBUTION – Chart given to doctor for diagnosis

20. USE – Evaluation of data – Diagnose, treat or refer?

21. MAINTENANCE – Should information be saved? • DISPOSITION – Chart destroyed or stored permanently