Deck 26: The Patient Record

Question 1

Progress notes should document the:

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

Answer 1

date, tooth number, and treatment.

Question 2

The dentist uses a patient _____ as the primary source of information to determine the overall quality of care the patient receives.

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

Answer 2

record

Question 3

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.

Answer 3

should be regarded as minimal information.

Question 4

Which of the following information-gathering forms is used to record the patient's overall health and dental status before any treatment is provided?

A)Patient registration
B)Medical-dental health history
C)Medical alert information
D)Consent

Question 5

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 6

The dental assistant should offer to aid the patient in completing 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)both b and c.

Question 7

The patient record is not considered a legal document.

Question 8

Once the information and diagnostic-gathering process has been completed,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 9

All dental practices now have a written privacy policy,required by _____,that must inform the patient that the office will not use or disclose Protected Health Information (PHI) for any purpose other than treatment,diagnosis,and billing.

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

Question 10

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

A)and insurance benefits
B)chronic conditions, allergies, and current medications being taken
C)chronic conditions, and allergies. Current medications is part of the patient registration form
D)and chronic conditions. Allergies and current medications are part of the clinical examination form

Question 11

A new patient who arrives for his or her initial appointment should be:

A)asked for his or her social security number.
B)asked to complete a 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

Employment information about the patient is located in which of the following patient record forms?

A)Patient registration
B)Medical-dental health history
C)Clinical examination
D)Treatment plan

Question 13

The most graphic and detailed form in the patient record is the _____ form.

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

Question 14

The dental team needs to be aware of the importance of properly documenting patient information because it not only helps in clinical patient care but also:

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

Question 15

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 16

The patient record consists of the:

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

Question 17

The _____ provides the patient with the expected outcomes of treatment and describes any possible complications.

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

Question 18

To ensure safe care to the patient,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 19

The patient record is:

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

Question 20

The _____ addresses all the patient's problems that were identified during the examination and diagnosis portion of the visit in a sequenced plan,and may include more than one option.

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

Question 21

Once patients review the HIPAA written policy,a form is signed 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 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

Quality assurance is vital in the delivery of dental care.What are some examples of quality assurance?

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

Question 24

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

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