Download DH 300 Ch07-nbJM

Working with Dental Office
Documents
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 The administrative assistant is
required to maintain clinical,
financial, employee, state, and
federal records.
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 The Health Insurance Portability and
Accountability Act (HIPAA) impacts the
dental business office.
 Provisions in HIPAA require national
standards for electronic healthcare
transactions.
 HIPAA was enacted in 1996 and became
effective in April 2003.
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 Protected patient health information is
anything that ties a patient’s name or
Social Security number to that person’s
health, healthcare, or payment for
healthcare, such as radiographs, charts, or
invoices.
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 The American Dental Association (ADA)
and most state dental associations
provide the necessary tools for the
implementation of HIPAA.
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 A HIPAA Security Tool Kit, available from
the ADA or state associations, contains
most of the forms needed for privacy
practices, including the following:
 Notice of Privacy Practices
 Receipt of Notice of Privacy Practices
 Business Associate Contract Terms
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 A record is data in forms such as text,
numbers, images, or voice that are kept
for future reference.
 Records management system refers to a
set of procedures used to organize, store,
retrieve, remove, and dispose of records.
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 Creation
 Distribution
 Use
 Maintenance
 Disposition
 Records need to be maintained in an office in
accordance with the statute of limitations
within each state.
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 Creation
 The origin of the information
 The necessity of retention is decided.
 The format in which it will be retained
is determined.
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 Distribution
 Where the record is sent and whom it will reach
 Use
 What is done with the information
 Maintenance
 Where and how the record is stored
 Disposition
 When and how the record should be destroyed or
stored permanently
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 Vital records
 Patient clinical and financial records
 Office’s corporate charter, mortgage, deed,
etc.
 Important records
 Accounts payable and receivable
 Invoices, canceled checks, inventory, payroll
records, and other federal records
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 Useful records
 Bank reconciliations, petty cash vouchers,
expired insurance policies
 This category can vary according to the office
definition.
 Unimportant records
 Those little notes and forms of little or no
value that just tend to lie around
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 Clinical record
 Components of all the treatment processes
are included in this record.
 Financial record
 Includes all listings of treatment with charges
and payments
 Includes insurance claim activity
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 Patient file envelope
or folder
 Clinical chart or
examination form
 Registration form
 Progress notes
 Health history and
 Dental diagnosis,
update forms
 HIPAA
acknowledgment
treatment plan, and
estimate sheet
 Medication history
and prescription
forms
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 Laboratory
 Postal receipts
requisitions
 Consent forms
 Consultation and
referral reports
 Letters
 Treatment
record/progress
notes
 Radiographs
 Copies of laboratory
tests
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 A file envelope or folder guards against
misplacement of patient records.
 Envelope style
 Patient records and radiographs are
slipped inside.
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 Folder style
 Has fastener for clinical records and a
pocket for radiographs
 Holds up better than file envelopes
 Problems include
 More expensive
 Have to bend tabs every time you want
to add an information sheet
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 Whether folders or envelopes are used,
some form of color-coding is necessary to
make sorting, storing, and retrieval easier.
 Color-coding can be done as an
alphabetical system or, in a group
practice, it can be categorized by
dentist.
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(Courtesy Patterson Office Supplies, Champaign, IL.)
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 Patient registration form
 Contains address, telephone numbers,
employment and insurance information
 Patient's e-mail address if applicable
 Correct information is needed for credit
checks.
 Incomplete information can complicate
account collection later.
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 A health history form contains a patient’s
medical information.
 An accurate and complete health history is a
preventive measure in patient treatment and
a defense in malpractice suits.
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 A health history
 Can be asked verbally if the patient is unable
to read; must be done in private
 Contains history of surgery, medications,
allergies, and other conditions that may
affect dental treatment
 Should be dated and signed
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 A health history update form should be
completed periodically to keep both the
health history and the personal
information current.
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 Consider the following when collecting patient
information.
 Ask the patient to arrive 15 minutes early to
complete the initial form, or mail the form to
the patient before the appointment.
 Place the form on a clip board and provide a
pen.
 Rather than say, “Can you fill this form out
for us?" say, “We would like you to complete
this history form so that we can give you the
best possible treatment."
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 Patient information
 Respect privacy when going over the form.
 Parents or legal guardian should complete
the form for children; likewise, parents
should be there when you are seeing children
under 18.
 Make sure the form is completed and signed.
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 The form is usually 8.5 × 11 inches on
heavy paper stock.
 May be die-punched to fit a file folder
 One side has a dental chart, review of
health history, and patient information.
 The chart may be used to draw existing
restorations and appliances, crowns,
and missing teeth.
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 Form
 The reverse side contains space for
treatment plan and notes.
 Pediatric versions are available for
children.
 Specialty charts are available for other
specialty areas.
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 A dental treatment plan and estimate form is
used when major dental work is indicated.
 May include treatment options
 For example: removable partial denture
(RPD), fixed bridges or implant
restorations
 Usually includes expected insurance benefits
 The form should be signed by the patient.
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Dental Treatment Plan
and Estimate Form
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 May be used when referring to another
dentist for examination, evaluation,
and/or diagnosis
 Can use a form or write a letter including:
 Information about the patient
 Reason for referral
 Anticipated treatment plan
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 A medication history can help prevent
drug interactions.
 List dates and nature of each
prescription.
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 A prescription for dental work to the
dental laboratory
 Specifies the materials and methods
used to create prosthetic dental devices
 States determine use of such a form if
required.
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 A record that the patient has had the
opportunity to ask questions about the benefits
and risks of a proposed treatment and is
making an informed decision regarding his or
her care.
 Commonly found in oral surgeons’ offices
 Attorneys usually want it signed by the
patient and doctor.
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 When a patient refuses to have
recommended treatment, the dentist
should have the patient sign a refusal-oftreatment form.
 This form includes the nature of the
treatment, alternative treatment,
treatment risks, and risks if NO
treatment is rendered.
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Refusal of Treatment Form
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 Letters
 All written communication sent to or regarding a
patient should be retained in the clinical record.
 Postal receipts
 Should be kept for things sent by certified mail
 Radiographic films
 May be kept in a coin envelope or mounts
 Need to be labeled
 It is recommended that original radiographs and
records be maintained in the patient chart.
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 If a sign-in sheet is used, caution should
be taken that a patient’s name is not
available to the public.
 A good way to ensure privacy is to use
sheets with tear-off labels.
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 All data entered in a patient’s clinical
chart or progress notes should be
 Dated
 Accurate and complete
 Initialed by the treating dentist
and assistant
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 Entering information on the patient’s
clinical chart or progress notes involves
the use of tooth numbering systems and
an assortment of abbreviations and
symbols.
 The administrative assistant must
understand each of these systems, as well
as the basic descriptions of the oral cavity.
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 Primary dentition has 20 teeth (A to T).
 Permanent dentition has 32 teeth (1 to
32).
 Mixed dentition has some primary and
some permanent teeth.
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 Universal numbering system
 Palmer notation system
 Federal Dentaire International system
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 1 to 32 for permanent teeth and A to T for
primary teeth
 Starts with the most posterior tooth in
the patient's maxillary right quadrant.
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 Assigns a bracket to each of the four
quadrants
 Starts with a 1 for the permanent tooth
and an A for the primary tooth at the
midline.
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 Assigns a two-digit number to each tooth in any
quadrant
 The permanent teeth are quadrants 1–4, and
the primary teeth are quadrants 5–8.
 The first number designates the quadrant in
which the tooth is found, and the second
number designates the specific tooth.
 Example: A 1 indicates a central incisor.
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 Teeth are divided into surfaces.
 Posterior teeth (the premolars and
molars) have five surfaces.
 Anterior teeth (the incisors and
canines) have four surfaces.
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 The mesial surface (M) is the surface
closest to the midline of the mouth.
 The distal surface (D) is the surface
farthest from the midline.
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 The facial surface (F) includes all tooth
surfaces that face the cheek and lips.
 The facial surfaces include the
 Labial surfaces (LA) found on anterior
teeth
 This term is rarely used.
 Buccal surfaces (B) found on posterior
teeth
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 The lingual surface (L) is the surface
closest to the tongue.
 The occlusal surface (O) is found only on
posterior teeth (the biting surface of the
teeth).
 The incisal edge (I) is found only on
anterior teeth that have a biting edge
rather than a biting surface.
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 Charting symbols are a form of shorthand
in the dental office.
 Clinical abbreviations are short versions
of or initials for common clinical
terminology.
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 Records must be retained in the office for
the period of time consistent with the
statute of limitations within the state.
 The statute of limitations is the period
within which a civil suit for alleged
wrongdoing may be legally filed.
 Varies from state to state
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 Must have consent from patient and only
that information for which consent is
given may be transferred.
 Never change the dental record prior to
transfer.
 Keep original records.
 A reasonable clerical fee may be charged
for furnishing the records in accordance
with local standards.
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 A professional fee may be charged for
preparing and furnishing a narrative
report for the patient.
 Require advanced payment for fees in
accordance with local standards.
 If records are mailed, send them certified
mail with a return receipt requested.
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 As important as a clinical record
 Maintained separately from clinical
record
 Protects the patient and the dentist
 Provides information for tax purposes
 Verifies data for business analysis
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 Classified into three categories
 Employment forms
 Employment tax information forms
 OSHA records relating to each
employee
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 Application for employment
 Employment agreements and contracts
 Merit evaluation forms
 Health and medical forms
 Federal Employment Eligibility
Verification forms
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 Employer ID number
 Amounts and dates of all wage, annuity, and
pension payments
 Names, addresses, Social Security numbers,
and documents of employees and recipients
 Sick or injury pay forms
 Employees’ and recipients’ income tax
withholding allowance certificates
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 Employee copies of W-2 forms that were
returned to the office
 Dates and copies of tax deposits filed
 Copies of returns files
 Record of fringe benefits
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 OSHA records relating to each employee
 Medical records
 Copies of employee hepatitis B vaccination
records or hepatitis B declination form
 Exposure incident forms
 Follow-up documents on exposure incidents
 OSHA training documentation
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