What’s in a dental record and why it’s important for you
As a dental patient, we often don’t know how much information is in our dental records. A few things may come to mind of the type of information patients think is recorded in a dental record. For example, X-ray, examination entries, or dental procedures are some of the information that is recorded. However, a dental record is a detailed and comprehensive medical document of any illness, physical examination, diagnosis, treatment, and management of a patient. This is a much more thorough record keeping than what patients normally think should go into a dental record. The law requires that medical professionals keep thorough records and maintained patient records for a duration of time. Among the general public, patients are becoming more aware of the valuable information in their medical or dental records. Every dental office you visit should keep a comprehensive and detailed records of patients. The primary reason for keeping such detailed record is to deliver quality care and for follow up visits.
What type of information is recorded in my dental records and how is it entered?
Your dental records may have information that ranges from X-rays, clinical photographs, drug prescriptions, laboratory results, any referral letters, and medical history. The information recorded should only be clinical data. No financial information should be in a dental record. For example, credit cards, insurance payments, or insurance benefit information.
In most practice, the dental staff who is in charge of maintaining the records will enter the information into a computer or document the information in a chart. Each record should be clearly written by either the dentist or staff member who is responsible for documenting your dental visit. The document should clearly detail which dentist treated you if the dental clinic is a large practice. In a dental record, a few examples of the types of information documented could include:
- General identification data (i.e name, date of birth, address).
- Any previous and current dental history.
- Clinical examination.
- Informed consent documentation.
- Family medical history.
- Ability to undergo a dental procedure.
How long are my dental records usually achieved?
In most dental practice, your dental records are either stored electronically or in actual paper charts. The dental practice will have two types of patient records in an active or inactive archive. As the names imply, active records are patient records that are in active use. Active records are always maintained on site. For patients, who have not visited the clinic in more than two years, their dental records are moved to inactive storage.
Now that you are aware of the information that is in your dental records, let our certified field agents help you retrieve your dental records. For more information, please contact Datafied at 800-765-7510 to schedule your next appointment
