Evidence Record: Dental Assessment, Medical History, and Procedures

This document presents an evidence record for dental assessment, covering various aspects of patient care and treatment. It begins with an introduction outlining the importance of proper management in dental care settings and utilizes assessment and graphical representations for effective operations. The main body includes detailed identification and explanation of dental records such as dental charts, radiographs, photographs, and study models, along with their uses. It addresses medical history, orthodontic measurements, and forensic charting. The record also explores reasons for selecting charts, medical conditions affecting treatment, and the importance of contemporaneous records. Furthermore, it details methods for monitoring physical characteristics, alerting clinicians to emergencies, and supporting patients during assessments. It also covers internal practice referral systems, communication strategies for patients experiencing pain or distress, and communicating the need for further assessment, including surgical procedures. References from books and journals are provided, and the document concludes with a learner and assessor signature section.

Purpose: to record learner evidence against a range of assessment methods
The Evidence Record needs to include a clear description of the evidence being presented to enable
the assessor to make appropriate assessment judgements.
This document can be used to record a range of assessment methods. For direct observations and
professional discussions, the Evidence Record needs to be completed by the tutor/assessor.
However, the learner can complete the Evidence Records for other evidence such as reflective
accounts or learner plans and records, the document can also be completed by Expert Witnesses to
record their statements.
Feedback in relation to the assessment recorded on this paperwork will be given on the assessment
cycle feedback sheet.
Learner / assessor
details
General information to identify the learner and tutor/assessor.
Assessment
method
The tutor/assessor should indicate which assessment method has been
used by adding the appropriate assessment method from the recommended
list for the qualification.
A list of recommended assessment methods can be found in Section 2 of
‘How to …’ A Guide to Assessing CACHE Qualifications, which is
available on cachezone.
Recording of
evidence
This section should provide a clear description of the learner’s practice to
enable the tutor/assessor to make their assessment judgements. It can be
completed by the tutor/assessor, the learner or the Expert Witness
dependent on the nature of the evidence.
Units /
Assessment
criteria
The evidence should be linked by the tutor/assessor to the range of units or
assessment criteria that it covers.
Signatures To be signed and dated by both the tutor/assessor and the learner to show
that they have both accepted the record.
Owner NQM ERF0513 V2.0

Learner name Date
PIN No Qualification
& level
Tutor/Assessor name
Assessment method
Direct observation Learner’s own work products
Professional discussion Question & answer
Reflection on own practice Other (please state below)
Owner: NQM ERF0513 V2.0

Recording of evidence
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INTRODUCTION
Providing the proper management will help in effective carrying out
of services that will help in proper management of operations in dental care
setting. Various assessment and graphical representations are been
presented that will help in proper management of dental care activities in
much effective way.
MAIN Body
TASK 1
1. Identify the dental records and give reason of their usage
Dental Records
and Chart
Insert Example Identify the
reason to use them
Dental chart It gives us the clear
idea about the
status of teeth
within buccal
cavity.
RadioGraphs We use the
Bitewing x-ray as
the major tool to
check out the inter
proximal surfaces
of teeth of caries
Owner: NQM ERF0513 V2.0

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Photographs The dental photo
graphs are been
taken in
consideration
before and after the
treatment, to
identify extent of
treatment.
Periodontal
chart
It helps to find the
positioning and
effectiveness of the
various types of
teeth in mouth.
Study models It gives the 3D idea
about the dentures
and teeth within a
mouth. It can be
refereed as the
guide for dental
structures and
studies.
Personal Details Name and dental Ailment related
to a person.
This will help in
the proper
assessment of the
business operations
and activities.
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Medical History
- Agreed
It will help the
dental care
providers to get the
proper idea about a
patients past
medical history
related to an
ailment.
Orthodontic
measurements
It gives the details
about the proper
management of the
teeth and the buccal
cavity that will
improve the idea
about dentures of
patients.
4) Forensic charting Assessment
5) 3 reason for selecting the charts
The major reason behind selecting charts records and diagrams
before dental assessment are:
 It makes the dental treatment easy.
 It helps the dental carer to identify the disease or ailment.
 It helps the practitioners to take proper precaution.
6) 3 medical conditions affecting dental treatment
3 dental condition that can affect an individual condition while
treatment are:
 High Blood pressure
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 Diabetes
 Tooth decay
7) importance of completing contemporaneous records and ther
documents after oral assessment
It is important to fill out all the assessment details and documents
for the recording of the oral assessment as it will help the firm or carer to
get the source for future reference and improve the quality of services and
thus will help in proper management of the oral assessment and treatment
process (Elad and et.al., 2015).
Task 3
1) Methods to monitor the physical characteristics
Physical characteristics of an individual can be monitored by various
ways such as:
 Heart beat / Minute
 Breathing rate
 Pulse rate
2) How to alert a clinician about a potential medical emergency
The clinician can be informed about a medical emergency by the
means of telephonic call. Text message or referring the medical reports of
the patients (Treloar and et.al., 2015). This will help him top make suitable
preparation to address the emergency.
3) Way to support patient during oral assessment
A patient can be carried out with proper assessment and
management of the treatment that is been carried out within an organisation
which will help in improving his health condition that will improve the
quality of services that are been performed within the organisation in much
suitable way (Ritter, 2017.).
Task 4
1) Internal practice referral system
It is a practice that will help in the proper management of medical
emergency by a doctor or dental practitioner. This will help in effectively
handling a serious condition or medical attention to a patient internally a
department or clinic.
The 3 forms and communication taken for the referral of patients are:
 patient referral form
 Medical history details
 Details of treatment undergoing
4 reason when patients are refereed to other team members:
 unavailability of main dental practitioner
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 Need of expertise to handle the medical case
 requirements of better treatment
 Preference by patients.
2) 3 ways to communicate a patient with pain or distress
 Encouraging the patient to bear the pain.
 Giving local anaesthesia
 Providing a proper painkiller and talk to the patient to pacify him.
3) How to communicate reason of further assessment
The need of further assessment will help in proper management of
treatment operations will help in reducing the severity of ailment. This can
be communicated either face to face or by producing a patient referral
document. It is important for having a proper treatment of dental disease.
4) Surgery procedure for further treatment
For the further treatment, Flap surgery or pocket reduction surgery
measure can be taken in consideration by the dental practitioner to treat a
severe dental ailment.
CONCLUSION
On the basis of evaluation, this can be said that the proper support
and help is required to carry out the effective dental assessment to a greater
extent.
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REFERENCES
Books and journals
Elad, S. and et.al., 2015. Basic oral care for hematology–oncology patients
and hematopoietic stem cell transplantation recipients: a position
paper from the joint task force of the Multinational Association of
Supportive Care in Cancer/International Society of Oral Oncology
(MASCC/ISOO) and the European Society for Blood and Marrow
Transplantation (EBMT). Supportive Care in Cancer. 23(1). pp.223-
236.
Ritter, A.V., 2017. Sturdevant's Art & Science of Operative Dentistry-E-
Book. Elsevier Health Sciences.
Treloar, C. and et.al., 2015. Evaluation of two community-controlled peer
support services for assessment and treatment of hepatitis C virus
infection in opioid substitution treatment clinics: The ETHOS study,
Australia. International Journal of Drug Policy. 26(10). pp.992-998.
Recording of evidence
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Owner: NQM ERF0513 V2.0

Recording of evidence
Unit
Assessment
criteria
Owner: NQM ERF0513 V2.0

Recording of evidence
Unit
Assessment
criteria
Learner name and
signature Date
Tutor/Assessor name
and signature Date
Owner: NQM ERF0513 V2.0