Module 3 – Clinical Records Management

The third module, focused on clinical records management, aims to provide students with a comprehensive understanding of the responsibilities related to maintaining and managing clinical records. Key learnings include:
 
The Legal and Medical Importance of Clinical Records:
 
   – Understand the legal obligation of dental clinics to maintain a record for each patient.
   – Recognize that well-maintained clinical records ensure continuity of care, protect the interests of both the dentist and the patient, and provide detailed information about the care provided.
 
Essential Components of a Properly Constituted Clinical Record:
 
   – Explore in detail the necessary administrative, medical, and dental data, such as the reason for consultation, medical history, odontograms, complementary examinations, treatment plans, care provided, follow-ups, prescriptions, oral hygiene, etc.
 
Managing Different Sections of the Clinical Record:
 
   – Learn what information to include in the dental clinical record. Examples include the reason for the visit, radiographs, treatments performed, advice given, prescriptions, laboratory test results, etc.
   – Understand the importance of recording any abnormal patient reactions and regularly updating the patient’s medical history.
 
The Role of the Dental administrative assistant:
 
   – Understand the role of the administrative assistant in preoperative coordination, communication of postoperative instructions, and appointment management.
   – Learn how to ensure consistency between handwritten and computerized information while maintaining data confidentiality.
 
Constituting an Emergency File:
 
   – Identify the key elements to include in an emergency file.
 
Precautions and Legal Protection:
 
   – Learn appropriate methods for making corrections to clinical records.
   – Understand the importance of well-documented records as a protective measure against potential lawsuits or complaints of malpractice.
 
Using Symbols in Dental Clinical Records:
 
   – Learn the main symbols used in dental clinical records to ensure accurate and quick communication.
 
Once mastered, this module will equip students with the necessary skills to effectively manage clinical records in a dental clinic, contributing to quality care delivery and regulatory compliance.