Transcription of Dental Record Keeping Guidlines
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Dental Record Keeping Guidlines
1 GUIDELINESA pproved by Council November 2019 This document replaces the version published in May Recordkeeping The Guidelines of the Royal College of Dental Surgeons of Ontario contain practice parameters and standards that should be considered by all Ontario dentists in the care of their patients. These Guidelines may be used by the College or other bodies to determine if appropriate standards of practice and professional responsibilities have been maintained. CONTENTSINTRODUCTION ..2 USE OF THIS DOCUMENT ..2 RECORDKEEPING BASICS ..2 GENERAL RECORDKEEPING PRINCIPLES ..3 GENERAL PATIENT INFORMATION ..3 MEDICAL HISTORY ..3 Follow-Up Questions and Review of Systems ..4 Recall History ..4 Dental HISTORY ..4 CONFIDENTIALITY AND PRIVACY ..5 COMPREHENSIVE CLINICAL EXAMINATION ..5 Vital Signs ..5 Extra-Oral Evaluation ..5 Intra-Oral Evaluation ..6 RADIOGRAPHIC EXAMINATION ..6 Initial Examination for New Patients ..7 Recall or Returning Patients.
Dental Recordkeeping. 3. General Recordkeeping Principles. Patient records must provide an accurate picture of the conditions present on initial examination, as well as the clinical
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