D.A’s responsibilities
Update medical history every appointment/visit and be accepting.
Patient record
Before any treatment, the dentist will request personal and clinical information from the patient
Patient registration
Primarily used for the business office in the management of the account. Need to be correct and accurate and have DEMOGRAPHIC, RESPONSIBLE PARTY, and INSURANCE Info.
Medical history
Patients past medical history, present physical condition, chronic conditions, allergies, and medications.
Medication history
A record of all medication a patient is currently taking includes prescription drugs, over the counter drugs, vitamins, or any other drugs. (Modify according to needs)
Allergies
Ask about known and suspected allergies. Allergies to latex, antibiotics, pain medication, and local/tropical anesthetic.
Medical alert
Sticker should never be placed on the outside of a patient record and should be placed on the inside front cover.
Dental history
Offers clues about previous dental care. NEVER trash talk a previous dentist NO matter what.
Health insurance portability and accommodation act (HIPAA)
Requires that all dental practices have a written policy that is available for review. ACKNOWLEDGMENT must be kept in patients record for a MINIMUM of 6 years.
Clinical info.
The medical and clinical histories are completed by the PATIENT in the examination findings and TREATMENT descriptions are completed by the DENTIST .
Clinical information
Clinical examination
Most detailed document in the patient record. It provides the dental team all examination data from the past present of future. The form will be updated each time a patient comes in.
Treatment plan and progress notes
TREATMENT plan address, dental problems, identify during examination and diagnose part of the patient
PROGRESS notes at the conclusion of each visit details of what was discussed diagnosed or clinically completed.
Vital signs
Indicator of patients overall health. Temp., pulse, respiration rate, and blood pressure.
Temp.
Avg. oral temp. Is 98.6(f) (37 c*)
Pulse rate
Normal pulse rate in resting adults is between 60 and 100 bpm. It is more rapid for a child 70 to 110 bpm.
Pulse
Radial (vitals)
Brachial (blood pressure)
Carotid (cpr)
Respiration
Normal respiration rate for a relaxed adult is 10 to 20 breaths per minute for children and teenagers. The rate ranges from 18 to 30 bpm.
Blood pressure (first s than d)
Refers to the amount of work the heart has to exert to pump blood throughout the body. The two readings are systolic pressure and the diastolic pressure. The systolic number is recorded over the diastolic number.
Blood pressure numbers and what they mean
Systolic is the first number and it indicates how much pressure your blood is exerting against your artery walls WHEN the heartbeats diastolic blood pressure is the. Second number and it indicates how much pressure your blood exerting against your arteries fall while the heart is resting BETWEEN beats.
Normal
Blood pressure numbers of less than 120/80 mm Hg are considered within the normal range if your results fall into this category stick with your healthy habits.
Elevated
When readings consistently ranged from 120-129 systolic and less than 80 mm Hg diastolic people with elevated blood pressure are likely to develop high blood pressure unless steps are taken to control the condition.
Hypertension stage one
Ranges from 130-139 systolic or 80-89 mm Hg diastolic doctors are likely to prescribe lifestyle changes and may consider adding blood pressure medication based on risk of cardiovascular disease such as heart attack or stroke.
Hypertension stage two
Blood pressure consistently ranges at 140/90 mm Hg or higher at this stage of high blood pressure doctors are likely to prescribe a combination of blood pressure medication and lifestyle changes.