Anyone looking forward to a career as a dental assistant can expect to spend a fair amount of time retrieving, updating and reviewing dental records. These are the records of a patient’s past appointments and procedures, any recorded issues and any other information relevant to their dental care, and taken together, they form a clear picture of that patient’s dental health and history.
If you’re just beginning dental assistant training or considering enrolling, and are curious to know more about these records, here’s a quick guide that will help you understand why they’re so important.
What’s Included in a Dental Record?
The contents of a dental record will vary between patients, who each have their own unique histories of treatment, but some information like age, date of birth, place of employment and contact information will always be included.
Other documents or information that can be found in a dental record include a complete record of appointments, past treatments and complaints, allergies and medications, clinical and radiographic findings, copies of test results, consent forms for invasive procedures and anaesthetizing, and any other information pertinent to a patient’s dental health, including relevant comments from dental assistants such as follow-up instructions given after a procedure.
Students in Dental Assistant Training Know the Importance of Continuity of Care
One of the most important functions of a dental record is to ensure continuity of care for patients. This means that when a patient moves or decides to change their dental care provider, their new dentist can rely on an accurate and up-to-date summary of their dental history and any ongoing issues when making their diagnoses.
This can be particularly important for issues like periodontal bone loss, which progress over time. A dentist examining a new patient with periodontal bone loss needs to know how quickly or gradually it’s progressing, whether it’s still progressing and how long it’s been happening, for example. These are all questions that can be answered by a complete and accurate dental record.
Even if a patient isn’t changing dental care providers, professionals who have completed their dental assistant training know that this record-keeping can be incredibly important in identifying, tracking and accurately diagnosing these types of long-term or progressive dental issues.
Dental records can be important in properly diagnosing long-term, progressive dental disease
Dental Records Can Be Important for Protecting Dental Professionals as Well
Not only do dental records ensure that patients receive the best possible care, but by keeping a clear record of treatment, dental practices can also protect themselves against complaints from patients and possible malpractice litigation. Documentation of a patient’s missed appointments or failure to follow instructions for further care, for example, can be important in accurately tracing blame for a subsequent issue, and protecting a dentist from liability for an issue which was not actually a result of any treatment they provided.
Dental Practices Have Clear Responsibilities Regarding Dental Records
Dental practices are responsible for keeping their patients’ dental records accurate and up-to-date. Patients actually own the information contained in their own records, and dentists are obligated by law to provide these records to other dental practices, or to the patients themselves if they request it. This is true even if a patient owes outstanding fees.
What this means for students in a dental assistant diploma program is that these records represent a very important element of a dentist’s legal obligations to their patients, as well an essential tool in providing them the best possible care, and so their proper maintenance, updating and storage is essential to the functioning of any well-run dental practice.
Accurate and up-to-date dental records are essential for any dental practice
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