Transcription of Dental Record Keeping Guidlines
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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.
health and any serious illnesses, conditions or adverse reactions in the past that might affect the dental management of the patient . In particular, the following key areas must be addressed for all patients: • history of any cardiovascular disease or condition • history of any immuno-compromising disease or condition
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