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REFERENCE M A N U A L V32/NO 6 10 111

Guideline on Reeord-keein<
Originating Council
Council on Clinical Affairs

Review Council
Council on Clinical Affairs

Adopted
2004

Revised
2007

Purpose data interehange with other professional and third parties.


The Ameriean Aeademy of Pdiatrie Dentistry (AAPD) reeog- The software must eontain all the essential elements of a tradi-
nizes the patient reeord is an essential eomponent of the tional paper reeord.
delivery of eompetent and quality oral health eare. It serves as The elements of reeord-keeping addressed in this guide-
an information souree for the eare provider and patient, as line are general eharting eonsiderations; initial patient reeord;
well as any authorized third party. This guideline will assist eomponents of a patient reeord; patient medieal and dental
the praetitioner in assimilating and maintaining a eompre- histories; eomprehensive and limited elinieal examinations;
hensive, uniform, and organized reeord addressing patient treatment planning and informed eonsent; progress notes;
eare. However, it is not intended to ereate a standard of eare. eorrespondenee, eonsultations, and aneillary doeuments; and
eonfidential notes. Additionally, appendiees to this guideline
Methods illustrate items for eonsideration in the development of pa-
This guideline was developed through reviews of eurrent litera- tient medieal and dental histories and examination forms.
ture, recommendations of the American Dental Association, These lists, developed by experts in pdiatrie dentistry and
and current record-keeping by pdiatrie dental resideney pro- offered to faeilitate exeellenee in practice, should be modified
grams, dental schools, and pdiatrie dental praetitioners, as well as needed by individual praetitioners. These samples do not
as eonsultation with experts in risk management. A MEDLINE establish or evidence a standard of eare. In issuing this infor-
seareh was eondueted using the keywords "reeord-keeping", mation, the AAPD is not engaged in rendering legal or other
"dental ehart", "dental reeord", "risk management", "eleetronie professional adviee. If sueh serviees are required, eompetent
patient reeord", and "eleetronie oral health reeord". legal or other professional eounsel should be sought.

Background Recommendations
The patient reeord provides all privileged parties with the General charting considerations
history and details of patient assessment and eommunieations The dental record must be authentic, accurate, legible, and
between dentist and patient, as well as speeifie treatment objective. Each patient should have an individual dental rec-
reeommendations, alternatives, risks, and eare provided. The ord. Ghart entries should contain the initials or name of the
patient reeord is an important legal doeument in third party individual making the note. Abbreviations should be standard-
relationships. Poor or inadequate doeumentation of patient ized for the practice. Risk management experts recommend
eare eonsistently is reported as a major eontributing faetor in a problem-oriented record.' After data collection, a list is
unfavorable legal judgments against dentists.''^ Therefore, the compiled that includes medical considerations, psychological/
AAPD reeognizes that a guideline on reeord-keeping may pro- behavior constraints, and the oral health needs to be addressed.
vide dentists the inform-ation needed to eompile an aeeurate Problems are listed in order of importance in a standardized
and eomplete patient ehart that ean be interpreted by a knowl- fashion making it less likely that an area might be overlooked.
edgeable third party. The plan identifies a general course of treatment for eaeh
An eleetronie patient reeord is beeoming more eommon- problem. This plan ean result in the need for additional
plaee.'-'' Advantages inelude quality assuranee by allowing eom- information, eonsultation with other praetitioners, patient
parative analysis of groups of patients or providers, medieal edueation, and preventive strategies.
and dental history profiles for dmographie data, support for
deeision making based on signs and symptoms, administrative
management for patient edueation and reeall, and eleetronie

260 CLiNICAL GUIDELINES


AMERICAN ACADEMY OF PEDIATRIC DENTISTRY

Initial patient record Hospitalizations/surgeries


The parent's/patient's initial contact with the dental practice, Anesthetic experiences
usually via telephone, allows both parties an opportunity to Current medications
address the patient's primary oral health needs and to confirm Allergies/reactions to medications
the appropriateness of scheduling an appointment with that Other allergies/sensitivities
particular practitioner. During this conversation, the reception- Immunization status
ist may record basic patient information such as: Review of systems
Patient's name, nickname, and date of birth Family history
Name, address, and telephone number of parent Social history
Name of referring party Appendix I provides suggestions for specific information
Significant medical history that may be included in the written medical questionnaire
Chief complaint or during discussions with the patient/parent. The history
Such information constitutes the initial dental record. At form should provide the parent additional space for informa-
the first visit to the dental office, additional information would tion regarding positive historical findings, as well any medical
be obtained and a permanent dental record developed. conditions not listed. There should be areas on the form indi-
cating the date of completion, the signature of the person pro-
Components of a patient record viding the history (along with his/her relationship to the
The dental record must include each of the following specific patient), and the signature of the staff member reviewing the
history with the parent/guardian. Records of patients with sig-
components:
nificant medical conditions should be marked "Medical Alert"
1. Medical history
in a conspicuous yet confidential manner.
2. Dental history
3. Clinical assessment
Medical history for adolescents'
4. Diagnosis
5. Treatment recommendations The adolescent can present particular psychosocial characteris-
6. Progress notes tics that impact the health status ofthe oral cavity, care seeking,
When applicable, the following should be incorporated into and compliance. Integrating positive youth development* into
the patient's record as well: the practice, the practitioner should obtain additional informa-
tion confidentially from teenagers. Topics to be discussed may
1. Radiographic assessment
include nutritional and dietary considerations, eating disorders,
2. Caries risk assessment
alcohol and substance abuse, tobacco usage, over-the-counter
3. Informed consent documentation
medications and supplements, body art (eg, intra- and extraoral
4. Sedation/general anesthesia records
piercings, tattoos), and pregnancy.
5. Trauma records
6. Orthodontic records
Medical updates
7. Consultations/referrals
At each patient visit, the history should be consulted and up-
8. Laboratory orders
dated. Recent medical attention for illness or injury, newly
9. Test results
10. Additional ancillary records diag-nosed medical conditions, and changes in medications
should be documented. A written update should be obtained at
Medical y each recall visit.
An accurate, comprehensive, and up-to-date medical history is
necessary for correct diagnosis and effective treatment planning. Dental history^'""
Familiarity with the patient's medical history is essential to A thorough dental history is essential to guide the practitioner's
decreasing the risk of aggravating a medical condition while clinical assessment, make an accurate diagnosis, and develop
rendering dental care. The practitioner, or staff under the super- a comprehensive preventive and therapeutic program for each
vision ofthe practitioner, must obtain a medical history from the patient. The dental history should address the following:
parent (if the patient is under the age of 18) before commencing Chief complaint
patient care. When the parent cannot provide adequate details Previous dental experience
regarding a patient's medical history, or if the dentist providing Date of last dental visit/radiographs
care is unfamiliar with the patient's medical diagnosis, consulta- Oral hygiene practices
tion with the medical health care provider may be indicated. Fluoride use/exposure history
Documentation ofthe patient's medical history includes the Dietary habits (including botde/no-spill training cup
following elements of information, with elaboration of positive use in young children)
findings: Oral habits
Medical conditions and/or illnesses Previous orofacial trauma
Name and, if available, telephone number of primary Temporomandibular joint (TMJ) history
and specialty medical care providers

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.REFERENCE MANUAL V 32 / NO 6 . 10111

Family history of caries patient should be included in these discussions. The dentist
Social development should not attempt to decide what the parent will accept or can
Appendix II provides suggestions for specific information afford. Afi:er the treatment plan is presented, the parent should
that may be included in the written dental questionnaire or have the opportunity to ask questions regarding the proposed
during discussions with the patient/parent. care and have concerns satisfied prior to giving informed con-
sent. Documentation should include that the parent appeared
Comprehensive clinical examination^'''''^ to understand and accepted the proposed procedures. Any
The clinical examination is tailored to the patient's chief special restrictions of the parent should be documented.
complaint (eg, initial visit to establish a dental home, acute
traumatic injury, second opinion). A visual examination should Progress notes
precede other diagnostic procedures. Components of a com- An entry must be made in the patient's record that accurately
prehensive oral examination include: and objectively summarizes each visit. The following informa-
General health/growth assessment tion should be included:
Pain assessment Date of visit
Extraoral soft tissue examination Reason for visit/chief complaint
TMJ assessment Adult accompanying child
Intraoral soft tissue examination Verification of compliance with preoperative
Oral hygiene and periodontal health assessment instructions
Assessment of the developing occlusion Changes in the medical history, if any
Intraoral hard tissue examination Radiographic exposures and interpretation
Radiographic assessment, if indicated'' Reference to supplemental documents
Caries risk assessment'* Treatment rendered, including anesthetic agents""
Assessed behavior of child and/or nitrous oxide/oxygen'^
Appendix III provides suggestions for specific information Patient behavior
that may be included in the oral examination. Post-operative instructions and prescriptions
The dentist may employ additional diagnostic tools to Anticipated follow-up visit
complete the oral health assessment. Such diagnostic aids may A standardized format may provide the practitioner a way
include electric or thermal pulp testing, photographs, labora- to record the essential aspects of care on a consistent basis. One
tory tests, and study casts. If the child is old enough to talk, example of documentation is the SOAP note.'* SOAP is an
the speech may be evaluated and provide additional diagnostic acronym for "subjective" (S) or the patient's response and feeling
information. to treatment, "objective" (O) or the observations of the clini-
cian, "assessment" (A) or diagnosis of the problem, and "proee-
Examinations of a limited nature dures aeeomplished and plans" (P) for subsequent problem
If a patient is seen for limited care, a consultation, an emergency, resolving aetivities. The signature or initials of the offiee staff
or a second opinion, a medical and dental history should be member doeumenting the visit should be entered.
obtained, along with a hard and soft tissue examination as When sedation or general anesthesia is employed, additional
deemed necessary by the practitioner. The parent should be doeumentation on a time-based reeord is required, as diseussed
informed of the limited nature of the treatment and counseled in the AAPD's Guideline for Monitoring and Management of
to seek routine comprehensive care. Pdiatrie Patients During and After Sedation for Diagnostic
The AAPD's Guideline on Management of Acute Dental and Therapeutic Procedures."
Trauma" provides greater details on diagnostic procedures and Progress notes also should include telephone conversations
documentation for this clinical circumstance. regarding the patient's eare, appointment history (ie, cancel-
lations, failures, tardiness), non-compliance with treatment
Treatment recommendations and informed consent recommendations, and educational materials utilized (both
Once the clinician has obtained the medical and dental histo- video and written), along with identification of the staff
ries and evaluated the facts obtained during the diagnostic member making the entry in the dental record.
procedures, the diagnoses should be derived and a sequential
prioritized treatment plan developed. The treatment plan would Orthodontic treatment
include specific information regarding the nature of the proce- The AAPD's Guideline on Management of the Developing
dures/materials to be used, number of appointments/time frame Dentition and Occlusion in Pdiatrie Dentistry^" and the
needed to accomplish this care, behavior guidance techniques, Ameriean Board of Pdiatrie Dentistry site visit requirements*
and fee for proposed procedures. The dentist is obligated to provide general recommendations on the documentation of
educate the parent on the need for and benefits of the recom- orthodontic care. Signs and/or symptoms of TMJ disorders
mended care, as well as risks, alternatives, and expectations if should be recorded when they occur before, during, or after or-
no intervention is provided. When deemed appropriate, the thodontic treatment.^' During orthodontic treatment, progress

262 CLINICAL GUIDELINES


AMERICAN ACADEMY OF PEDIATRIC DENTISTRY

notes should include deficiencies in oral hygiene, loose bands Environmental (ineluding latex, food, dyes, metal,
and brackets, patient complaints, caries, root rsorption, and aerylie)
eaneellations and failures. Medieations (ineluding over-the-eounter analgsies, vitamins,
and herbal supplements)
Correspondence, consultations, and ancillary documents
Dose
The primary eare dentist often eonsults with other health eare
Frequeney
providers in the eourse of delivery of comprehensive oral health
care, espeeially for patients with speeial health eare needs or Reactions
eomplex oral eonditions. Communieations with medieal care Hospitalizationsreason, date, and outcome
providers or dental specialists should be ineorporated into the Surgeriesreason, date, and outeome
dental reeord. Written referrals to other eare providers should Signifieant injuriesdeseription, date, and outeome
inelude the speeifie nature of the referral, as well as pertinent Ceneral
patient history and elinieal findings. A progress note should be Complieations during pregnaney and/or birth
made on eorrespondenee sent or reeeived regarding a referral,
Prematurity
indieating doeumentation filed elsewhere in the patient's chart.
Copies of test results, preseriptions, laboratory work orders, Congenital anomalies
and other aneillary doeuments should be maintained as part of Cleft lip/palate
the dental reeord. Inherited disorders
Nutritional defieieneies
Confidential notes Problems of growth or stature
The praetitioner may eleet to keep on a separate form subjee- Head, ears, eyes, nose, throat
tive notes addressing impressions and opinions of the doetor Lesions in/around mouth
and/or staff concerning parent/patient interactions that may ehronie adenoid/tonsil infeetions
or did result in negative eonsequenees.
ehronie ear infeetions
Ear problems
Appendices*
*The information ineluded in the following samples, developed Hearing impairments
by the AAPD, is provided as a tool for pdiatrie dentists and Eye problems
other dentists treating children. It was developed by experts Visual impairments
in pdiatrie dentistry and is offered to faeilitate exeellenee in Sinusitis
praetiee. However, these samples do not establish or evidenee a Speeeh impairments
standard of eare. In issuing this information, the AAPD is not Apnea/snoring
engaged in rendering legal or other professional adviee. If sueh
Mouth breathing
serviees are required, eompetent legal or other professional
counsel should be sought. Cardiovaseular
Congenital heart defeet/disease
Appendix IMedical history* Heart murmur
Name and niekname High blood pressure
Date of birth Rheumatie fever
Cender Rheumatie heart disease
Raee/ethnieity Respiratory
Height, weight by report Asthmamedieations, triggers, last attaek,
Name, address, and telephone number of all physieians hospitalizations
Date of last physieal examination Tubereulosis
Immunization status Cystie fibrosis
Summary of health problems Frequent eolds/eoughs
Any health eonditions that neeessitate antibioties prior Respiratory syneytial virus
to dental treatment Reaetive airway disease/breathing problems
Allergies/sensitivities/reaetions Smoking
Anestheties, loeal and general Castrointestinal
Sedative agents Eating disorder
Drugs or medieations Uleer
Exeessive gagging

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REFERENCE MANUAL V 32 I NO 6 10/11

Castroesophageal/acid reflux disease Alcohol and chemical dependency


Hepatitis Emotional disturbance
Jaundice Hyperactivity/attention deficit hyperactivity
Liver disease disorder
Intestinal problems Psychiatric prohlems/treatment
Prolonged diarrhea Endocrine
Unintentional weight loss Diabetes
Lactose intolerance Crowth delays
Dietary restrictions Hormonal problems
Cenitourinary Precocious puberty
Bladder infections Thyroid problems
Kidney infections Hematologic/lymphadc/immunologic
Pregnancy Anemia
Systemic hirth control Blood disorder
Sexually transmitted diseases Transfusion
Musculoskeletal Excessive bleeding
Arthritis Bruising easily
Scoliosis Hemophilia
Bone/joint problems Sickle cell disease/trait
TMJ problemspopping, clicking, locking, Cancer, tumor, other malignancy
difficuldes opening or chewing Immune disorder
Integumetary Chemotherapy
Fever blisters Radiation therapy
Eczema Hematopoietie cell (bone marrow) transplant
Rash/hives Infectious disease
Dermatologie eonditions Measles
Neurologie Mumps
Fainting Rubella
Dizziness Scarlet fever
Autism Varicella (chicken pox)
Developmental disorders Mononucleosis
Learning problems/delays Cytomegalovirus (CMV)
Mental disability Pertussis (whooping cough)
Brain Injury Human immunodeficiency virus/acquired Immune
Cerebral palsy deficiency syndrome (HIV/AIDS)
Convulsions/seizures Family history
Epilepsy Cenetic disorders
Headaehes/migraines Prohlems with general anesthesia
Hydroeephaly Serious medical condidons or illnesses
Shuntsventrieuloperitoneal, ventriculoatrial, Social concerns
ventriculovenous Passive smoke exposure
Psychiatric Religious or philosophical objections to treatment
Abuse

264 CLINICAL GUIDELINES


AMERICAN ACADEMY OF PEDIATRIC DENTiSTRY

Appendix IIDental History* Appendix IIIClinical Examination*


Previous dentist, address, telephone number General health/growth assessment
Family dentist Growth appropriate for age
Date of last visit Height/weight/frame size/body mass index (BMl)
Date of last dental radiographs, number and type taken, Vital signs
if known Blood pressure
Prenatal/natal history Pulse
Family history of earies, ineluding parents and siblings Extraoral examination
History of smoking in the home Facial features
Medieations or disorders that would impair salivary flow Nasal breathing
Injuries to teeth and jaws, ineluding TMJ trauma Lip posture
When Symmetry
Treatment required Pathologies
Dental pain and infeetions Skin health
Habits (past and present) sueh asfinger,thumb, paeifier, Temporomandibular joint/disorder (TMJ/TMD)'^
tongue or lip sueking, bruxism, elenehing Signs of clenching/bruxism
Snoring Headaches from TMD
Diet and dietary habits Pain
Breast feedingfrequeney Joint sounds
Bottle feeding/no-spill training (sippy) eup use Limitations or disturbance of movement or
Frequeney function
Formula, milk water, juiee Intra-oral soft tissue examination
Weaned/when Tongue
Sodas, fruit juiee, sports drinks, beverages Roof of mouth
amount, frequeney Frenulae
Snaekstype, frequeney Floor of mouth
Mealsbalaneed Tonsils/pharynx
Oral hygiene Lips
Frequeney of brushing, flossing Pathologies noted
Assisted/supervised Oral hygiene and periodontal assessment^^'^'
Fluoride exposure Oral hygiene, including an index or score
Primary souree of drinking waterhome, Gingival health, including an index or score
dayeare, other Probing of pocket depth, when indicated
Watertap, bottled, well, reverse osmosis Marginal discrepancies
Systemie supplementationtablets, drops Galculus
Topicaltoothpaste, rinses, prescription Bone level discrepancies that are pathologic
Previous orthodontic treatment Recession/inadequate attached gingiva
Behavior of child during past dental treatment Mobility
Behavior anticipated for future treatment Bleeding/suppuration
Furcation involvement
Assessment of the developing oeelusion
Faeial profile
Ganine relationships
Molar relationships
Overjet
Overbite

CLINICAL GUIDELINES 265


REFERENCE MANUAL V 32 / NO 6 10 11

Midline References
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Crowding 2. Bressman JK. Risk management for the '90s. J Am Dent
Centric relation/centric occlusion discrepancy Assoc 1993;124(3):63-7.
3. Heid DW, Chasteen J, Forrey AW. The electronic oral
Influence of oral habits
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Appliances present
4. Atkinson JC, Zeller GG, Shah C. Electronic patient re-
Intraoral hard tissue examination cords for dental school clinics: More than paperless sys-
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Over-retained primary teeth approach. J Greater Houston Dent Soc 1994;65(9):46-8.
Ankylosed teeth 6. Nelson GV. Guidelines to the prevention of problems in
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Tooth size, shape discrepancies 8. American Board of Pdiatrie Dentistry. Site Visit Hand-
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Enamel hypoplasia pamphlets/sitevisit_handbook.pdf". Accessed March 18,
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Caries
10. American Academy of Pdiatrie Dentistry. Guideline
Pulpal pathology^'*
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CLINICAL GUIDELINES 267


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