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Dental Records: Best Practices for Information Management and Retention

Course Number: 532


alteration – A change or revision in a record.

breach of contract – Failure to act as required by a contract.

CAD/CAM – A prosthodontic technology for dentistry that used “computer-aided design” and “computer-aided manufacturing” to create in-office restorations; ex. crown, inlay, onlay.

CBCT – stands for cone-beam computed tomography; renders a three-dimensional image of the patient’s oral cavity to include teeth and jaw as well as ears, nose, and throat.

chart – A portion of the complete patient record; the chart receives documentation including dates, treatments, radiographs, instructions, medications, laboratory needs, referral information, and recommended recall.

chartless – A practice that continues to use paper forms but they are scanned into the electronic record and then shredded.

clinical – Pertaining to the chairside treatment of the patient.

cloud computing – The “cloud” is a metaphorical term for the internet; this type of system uses several internet servers to save and secure data, and this data can be accessed from any device with internet access.

confidential — Information to be kept private and secure.

contract – An agreement between two or more parties that is enforceable by law.

current dental terminology (CDT) – A list of descriptive terms and identifying codes maintained by the American Dental Association for reporting dental services and procedures to dental benefit plans.

EHR – Acronym for electronic health record.

ePHI – Acronym for electronic protected health information.

financial records – Kept separate from the treatment records, financial records contain the patient information regarding their billing and payments for services rendered.

HIPAA – Acronym for Health Insurance Portability and Accountability Act of 1996.

implied consent – Consent that is established by actions, not written words.

informed consent – Voluntary agreement by a person after knowing sufficient details to make an informed decision to accept treatment.

informed refusal – Voluntary agreement by a person to refuse treatment after knowing sufficient details to make an informed decision.

malpractice – Professional negligence.

negligence – Failure to provide a reasonable level of care.

Notice of Privacy Practices – Required under HIPAA; written notification informing patients of the office’s policies related to the use and disclosure of their protected health information.

objective statement – Factual information; not influenced by opinion.

obliterate – To destroy completely, leaving no trace.

Palmer Notation System – Also known as the Symbolic Numbering System, this is a tooth numbering system used often by orthodontic practices.

paperless – When a dental practice uses only electronic records.

patient record – The patient record is comprised of the patient information forms, clinical treatment forms, financial transaction forms, radiographs, and study models.

Privacy Contact – Required under HIPAA; the designated individual in the office responsible for providing information, receiving complaints, and handling the administration of patients’ rights.

Privacy Officer – Required under HIPAA; the designated individual in the office responsible for developing and implementing the policies and procedures necessary for HIPAA compliance.

PHI – Acronym for protected health information.

scrutiny – A searching examination or investigation.

SOAP Notes – A charting acronym which stands for entries that follow Subjective, Objective, Assessment, and Plan notations.

Standard of Care – The legal duty of a dentist to exercise a degree of skill and care that would be exhibited by other prudent dentists.

subjective statement – Information that is influenced by personal feeling or opinion.

TCPA – Telecommunication Consumer Protection Act; protects consumers from excessive contact via phone calls and text messages.

teledentistry – Using technologies such as phone, tablet, and computer to deliver virtual dental education and services.

third-party back up system – Using an office site company to back up and secure data.

Universal Numbering System – A tooth numbering system to identify a specific tooth.