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