Chapter 4   Patient Chart

4-1. Patient Chart.

Detailed instructions concerning the management of the dental health record can be found in the Oral Diagnosis Syllabus.  For the initial appointment with a patient, the student should have obtained the Patient Chart from the Central Records Area on the first floor.  The Patient Chart Jacket will contain the following items:  The Patient Clinic Chart, radiographs taken at the screening appointment, work sheets for pathosis findings, schematic, and proposed treatment plan.  Each item is discussed in the following paragraphs and more detailed information will be found in the Department of Oral Diagnosis Syllabus of Clinic Procedures. 

4-2. Patient Chart Jacket.

There are several features to be noted on the cover of this jacket.  The label in the upper right-hand corner identifies the name of the patient, address, phone number and date of birth.  Directly below this is a label indicating the assigned student and their identifying number.  A medical alert stamp or sticker, if indicated, will be placed inside the back cover along the top edge of the chart. 

4-3 Patient Clinic Chart.

The Oral Diagnosis Syllabus of Clinic Procedures presents step-by-step instructions for proper completion of the CHART. 

Of special interest are the following:

       Referral of Treatment Steps - Step Referral Form:  

a.       Treatment steps may be referred from one student to another only for good reason and with the approval of the patient and the faculty.  Patients who are treatment planned for removable partial dentures will be reassigned only.  Approval for the reassignment of removable partial denture and complete denture patients would be given by your coordinator.  The referral of restorative steps involving single castings and/or fixed partial dentures will be approved so as to comply with the sequence plan which was developed with the faculty of the Oral Rehabilitation Department.  Endodontic procedure referrals may be approved but not assigned by any of the Endodontics faculty

b.       Prior to the beginning of treatment, the step referral form must be completed and signed by the students.  The form must also be signed by the appropriate coordinator/faculty giving approval for the referral.  The student providing the treatment will present the completed step referral form along with the desired appointment information (time and day of appointment, clinic in which appointment is desired, anticipated procedure) to (Director of Patient Services) in Clinic 12 on the Second Floor.

Patient's Informed Consent Signature

a.       Patient's Informed Consent

It is imperative that the patient's signature appears in the appropriate place on this form. Only after the student has discussed the proposed treatment and the patient signifies that he understands the proposals and agrees to them should the student request them to sign and date this form.

b.       Consent For Treatment of Juveniles and Emancipated Minors

Patients who are thirteen to seventeen years old are not required to have parents or guardians in the waiting room at each visit.

However, the parent or guardian must be present at the first visit to sign a statement verifying correctness of the health/dental history and giving permission for the examination and collection of diagnostic information.  Only those over 18 may sign and verify their information.

Following development of the treatment plan and possible treatment alternatives, the parent or guardian must sign the informed consent before further treatment can be provided.  The parent/guardian may either be present at the diagnostic review appointment to sign the proposed treatment plan or a copy of the written treatment plan may be taken home for the appropriate signature.  When the signed treatment plan has been returned, the student must contact the parent/guardian by phone to review the treatment plan and answer any questions.  A note of this conversation must be included in the progress notes.

Emancipated minors

Emancipated minors will be considered as adults.  They may sign for permission to initiate examination and collection of diagnostic information.  They may sign the informed consent for further treatment, following presentation of the treatment plan.

Treatment Record and Progress Notes

A.      Treatment Record and Progress Notes:  This portion of the Dental Patient Record represents a summary of all the therapy performed for the patient at the Medical College of Georgia, School of Dentistry.  This is the legal record for this patient and must be carefully and completely maintained.

1.       Treatment performed:  A brief description of each activity performed should be recorded in this column. 

2.       Every patient encounter for treatment, consultation, or cancellation should be recorded.  If a patient calls to cancel an appointment, this conversation should be recorded.

3.       Instructor:  Each entry in the treatment record section of the chart should be signed by an instructor, even if it is a cancellation or broken appointment.  

B.      Importance of Patient Chart 

Since the patient record form constitutes the legal record of professional treatment performed for this patient, it is extremely important for both the student and the instructor to review all entries for accuracy and completeness and place their name or initials, whichever is applicable, in the spaces provided.  The importance of this aspect of record management cannot be emphasized too strongly.

C.      Pediatric Patient Clinic Chart:  The Pediatric Patient Clinic Chart is similar to the Patient Chart just described with special emphasis on pediatric problems and activities.  The Pediatric Dentistry Department provides special instructions on the proper maintenance of this form. 

The Medical College of Georgia
is an Equal Opportunity Educational Institution.