If physician communication for treatment occurs, the clinician should record these contacts. Earlier medical histories should be retained in the chart for future reference. Periodically the patient should provide an entirely new updated form rather than changing data on the old form. If any changes occurred, the patient should identify each updated medical change, the date, and sign the form where indicated for medical update information. If no changes are necessary, the patient should date and sign the history form. The patient should be asked to review the previous and current medical history ( Fig. Medical histories must be updated periodically (or at least annually or sooner as the need arises). Knowledge about current medications, medical therapy, and the name and address of the treating physician is essential. ![]() The clinician may request that the patient be examined by a physician or undergo laboratory testing under medical supervision to determine whether a suspected medical problem may require attention before endodontic therapy proceeds or if drug sensitivity or an allergy mandates treatment modifications. Health questionnaires open avenues for discussion about problems of major organ systems and important biochemical mechanisms, such as blood coagulation, allergy, immunocompromised status, need for antibiotic prophylaxis, and disease susceptibility. The clinician should thoroughly review the patient’s past and present health status before proceeding so that dental treatment can be safely initiated. Questions about dental insurance and financial responsibility are included on the form to avoid any later misunderstandings and help fulfill federal requirements of the Truth in Lending law, applicable if four or more installment payments are arranged (whether or not there are interest or late-payment charges). In the event the patient is a minor, the responsible parent or guardian should provide the information. Location information about the patient’s spouse, relative, or a close friend who can be notified in an emergency is also suggested. The patient’s name home, business, and e-mail addresses and telephone and fax numbers are needed to contact the patient for scheduling purposes and inquire about postoperative sequelae. Necessity and reasonableness of diagnosis and treatment capable of peer review and dental insurance carrier evaluationĪdverse reactions or events with explanationįollow-up comments to medical history–positive responsesĪ patient information form provides essential data for patient identification and office communication, which should be updated periodically ( Fig. Log of records and radiographs received or sentĭental records should document the following information:Ĭourse of therapy by recorded diagnosis including differential diagnoses, informed consent or refusal, treatment, and prognosisĬommunications among the treating clinician, other health care providers, consultants, subsequent treating practitioners, and third-party carriers Patient phone numbers including home, work, and cell Name or initials of author for each treatment entryĮmergency contact persons, addresses, and phone numbers ![]() Referrals, including patient refusals (if any)Ĭommunications with other health care providersĬanceled or missed appointments and stated reasons ![]() Pulpal and periodontal diagnostic tests performedĭifferential diagnoses and final diagnosis Medical (periodically updated) and dental history ContentĮndodontic treatment records should include the following information: Records also are fundamental means of communication among health care professionals. The dental record must contain sufficient information to identify the patient, support the diagnosis, justify the treatment, and document the course and result of treatment, and it should be designed to protect the patient’s welfare. Documentation is essential to attaining endodontic excellence. Endodontic therapy records serve as an important map to document and guide the clinician’s journey down the correct diagnostic and treatment path.
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