Example of Dental records and charts

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TASK 1
Dental records and charts
Dental records refers to the detailed document containing history of physical
examination, illness, diagnosis,treatment and administration of patient. In dental practice,
comprehensive as well as accurate records are vital part. These records provides for care
continuity for patient and is censorious in malpractice insurance claim event.
Insert example
Examples of dental records includes:
 Identification data which includes name, phone numbers, date of birth and emergency
contact information of patient.
 Dental history
 Clinical examination to add an accurate charting
 Diagnosis
 Treatment plan
 Documentation of informed consent
 Medical history of patient which includes through investigation including name and
number of professional, evaluation of general health and appearance of patient, list of
diseases like hepatitis, diabetes, rheumatic fever, any drug allergies, bleeding disorders,
cardiac disorders, ongoing medical treatment etc.
Identify why we use them
Complete and diligent record keeping and protecting health information is highly
important for many reasons. The prime purpose of maintaining records and charts is to evaluate
and deliver quality care and follow-up to patient. Besides this, dental records provides enough
data and information that allow provider to know the dental experience of patient. It may be
utilized in court of law in order to establish diagnostic information and data that was received
and the treatment which was provided to patient.
Dental chart
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(Source: Human Teeth Dental Chart, 2019)
Including Baseline
(Source: Baseline Chart, 2019)
Radiograph
Dental radiographs are commonly known as X-rays which are used by dentists to find
malignant masses, hidden dental structures, cavities and bone loss. It provides images of teeth
that are used by dentist to evaluate oral health.
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Illustration 1: Human Teeth Dental Chart
Illustration 2: Baseline Chart

(Source: Dental Radiographs, 2015)
Bitewing X-ray
Bitewing x-rays demonstrates the crowns of pre-molar and molar teeth and height of
bone between teeth. It helps in diagnosis of periodontal and cavity disease. It is used to check
inter-proximal surfaces of teeth for caries.
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Illustration 3: Dental Radiograph

(Source: Bitewing X-rays, 2019)
Periodontal charts and BPE
Periodontal chart is a graph used by dental care professionals to record and write the
overall oral conditions and gingival related to periodontal disease or health. Basic periodontal
examination (BPE) is a simple and fast scanning tool which is use to indicate needed
examination level and to administer basic guidance on need of treatment.
(Source: Periodontal Chart, 2019)
Study models
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Illustration 4: Bitewing X-rays
Illustration 5: Periodontal Chart

(Source: Dental study models, 2019)
(Source: Dental Demonstration Model, 2019)
Personal details
The patient is suffering from tooth decay which is occurs when plaque forms on teeth
mix with sugar and starches of food an individual eat.
Medical history – agreed
The patient is not suffering from any other medical disorder.
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Illustration 6: Dental study models
Illustration 7: Dental Demonstration Model

Orthodontic measurements
Intra-oral photographs and radiographs are utilized for orthodontic diagnosis and
planning of treatment.
Lab sheets
It is advised to brushing twice a day, get regular check-ups, flossing daily in order to
prevent tooth decay.
TASK 2
How would you monitor support and manage signs of distress in the following patient
groups?
During dental surgery, it is essential for practitioners to concern on reducing dental
anxiety and phobia among patients. They have to make proper interaction with patients to reveal
the presence of anxiety, phobia and fear related to surgery process. For example: To deal with
adults, dentist need to make proper interaction with them and must tell about whole procedures.
This would provide relaxation to adults and helps in convincing them for further treatments. In
this regard, major problems faced by practitioners are giving treatment to children because they
have much feared with dental procedures, which often leads to resistivity as well. For this
purpose, by making friendly behaviour with kids through learning and psychotherapeutic
intervention, dentist can reduce fear and level of anxiety of children. Along with this, patients
belong to high age or having special needs, through cognitive therapy, conscious sedation and
pharmacological intervention, fear of them can also be reduced.
TASK 3
Why would we refer patients to other team members and how is this done or
communicated within your practice?
Patients are refer to other team members in order to provide them better care. It is done to
provide accurate treatment to patient. In dental care practice, professionals are work collectively
to render effective and high quality services. By using dental records and charts, all the
informations related to patients are communicated to other team members. This will help them in
knowing about the condition of patient which is helpful in providing them needed treatment.
Referral of patient is done by assessing actual condition of patient. In dentistry, professionals
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first evaluate dental and oral health needs. After then, they treat or refer patient for speciality
care which depends on the condition they diagnose.
Examples of the equipment, instruments and materials used for the following purposes:
Observing hard and soft tissues
 Sickle probe
 Dental mirror
 Periodontal probe
 Excavators
Measuring and making a record of the teeth and gingivae
 Periodontal probe
 Periodontal chart
Assessing the function of the dentition (orthodontic assessment)
 Gloves
 Visor
 Mask
 Patient bib
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