Deck 26: The Patient Record

Question 1

Properly documenting patient information helps in clinical patient care and:

A)conveys a legal significance of which the dentist and assistant must be aware.
B)contains has a large volume of information.
C)both a and B
D)none of the above.

Answer 1

both a and B

Question 2

The primary source of information used to determine the overall quality of care the patient receives is the:

A)patient record.
B)encounter form.
C)patient survey.
D)treatment plan.

Answer 2

patient record.

Question 3

Expected outcomes of treatment and description of possible complications are recorded on the:

A)treatment plan.
B)informed consent form.
C)clinical examination.
D)progress notes.

Answer 3

informed consent form.

Question 4

To ensure patient safety,medical alerts and other precautions should be noted by:

A)posting a warning sign on the entrance to the treatment area.
B)writing the medical condition that prompted the alert on the patient bib.
C)affixing an "alert" sticker to the outside cover of the patient record.
D)affixing an "alert" sticker to the inside cover of the patient record.

Question 5

The patient record is not considered a legal document.

Question 6

Progress notes should document the:

A)date, tooth number, and treatment.
B)different treatment alternatives.
C)payment method.
D)use of insurance benefits for the current calendar or contract year.

Question 7

The patient record consists of:

A)the patient registration form and HIPAA form.
B)the medical-dental health history form, the medical alert information form, and radiographic examination.
C)the clinical examination form and consent forms.
D)all of the above.

Question 8

The written medical-dental health history form:

A)eliminates the need for a face-to-face conversation with the patient.
B)should be regarded as minimal information.
C)does not need to be signed and dated by the patient to certify that the information is correct.
D)is considered to be part of the treatment plan.

Question 9

A written privacy policy informing a patient that an office will not use or disclose Protected Health Information (PHI)for any purpose other than treatment,diagnosis,and billing is mandated by:

A)HIPAA.
B)OSHA.
C)NHII.
D)ADA.

Question 10

The most graphic and detailed form in the patient record is the:

A)patient registration form.
B)clinical examination form.
C)treatment plan.
D)progress notes.

Question 11

A patient who reports for an initial appointment should be:

A)asked to provide a social security number.
B)asked to complete a medical and dental history, and be told why the information is needed.
C)asked to fill out patient forms and answer questions over the phone.
D)notified that the form does not need to be signed.

Question 12

A patient's medical-dental history should be updated:

A)once a year.
B)every time the patient comes into the office.
C)every 6 months.
D)only after a major illness.

Question 13

A patient's employment information is located on the:

A)patient registration form.
B)medical-dental health history.
C)clinical examination form.
D)treatment plan.

Question 14

A treatment plan is properly sequenced to address all problems that were identified during the examination and diagnosis portion of the patient visit,and can include more than one option for treatment.

Question 15

At the completion of the diagnostic gathering process,the dentist will:

A)review all significant findings.
B)present a diagnosis to the patient.
C)develop and document a treatment plan with input from the patient.
D)formulate an assessment from the findings of the patient's oral health status.

Question 16

Before treatment,a patient's overall health and dental status is recorded on a:

A)patient registration.
B)medical-dental health history.
C)medical alert information.
D)consent form.

Question 17

The medical history section includes questions regarding the patient's past medical history,present physical condition,and:

A)insurance benefits
B)chronic conditions, allergies, and current medications being taken
C)chronic conditions, and allergies.
D)and chronic conditions.

Question 18

The patient record is:

A)a temporary document.
B)a permanent document.
C)not considered a legal document.
D)not sufficient enough to be used as a reference tool in a forensic case.

Question 19

The clinical examination form includes:

A)the plan of care.
B)charting for existing restorations and present conditions.
C)progress notes.
D)informed consent.

Question 20

The dental assistant should offer to help the patient to complete the medical-dental history form:

A)to be sure the patient is truthful.
B)because there may be a language barrier.
C)because the patient may not understand the terminology used.
D)for both b and C

Question 21

The goal of obtaining medical history information from a dental patient is to:

A)become informed of any existing allergies to foods or medications.
B)be alert of any medical conditions.
C)identify special treatment needs of the patient.
D)ensure all of the above.

Question 22

The written policy that must be provided to all patients regarding patient right to privacy is called:

A)PHI.
B)HIPAA.
C)medical alert information.
D)none of the above.

Question 23

After patients review the HIPAA written policy,they sign a form that:

A)states that the patient understands the privacy policy.
B)acknowledges the patient's receipt of the privacy policy.
C)states that the patient understands the Patient Bill of Rights.
D)states that the patient understands OSHA.

Question 24

Examples of quality assurance,vital to the delivery of dental care,include:

A)completing treatment in one appointment.
B)timely recall of patients to address dental need and documentation of when radiographs were taken.
C)current, up-to-date emergency standards maintained by the dental team and current and up-to-date licenses, registrations, and training of dental team members.
D)both b and C